an expert on how to get what you need from your health insurance

An Ask a Manager reader who works in health insurance as a customer service trainer wrote to me and offered to give advice about navigating health insurance, saying, “Basically, I get paid to learn and teach how to beat the system as much as possible. I love my job as much as I hate this industry and system, so I’m always game to help people out and answer questions … I teach customer care reps, so I’m teaching them the rules, why things happen like they do, and then how to find the wiggle room and exceptions so that we can actually take care of providers and consumers. That looks like things we can do within the insurance itself like adjusting claims or nudging consumers to ask for reviews of denied prior authorizations, to reaching out to provider billing offices to mediate billing issues. There’s also a lot of explaining, educating, and directing to resources (in the company like our in-house care management, as well as externally like EAPs or community resources).”

I said yes, we want her tips! She put together this Q&A to help people.

How do I know what plan to pick? 

If your employer offers multiple plans, look at the value of predictability as well as the overall out of pocket maximum. If you prefer to know exactly what you’re going to pay every time you go to the doctor, a copay plan will likely work best. If you have lots of medical expenses, especially early in the year, a deductible plan might work best. If you need the options explained to you, you can either talk to your benefits coordinator at work or call the insurance company to talk through coverage and cost.

What if my prior authorization or referral gets denied? 

Call your insurance company. When you get to a rep, have them confirm that the authorization is still denied. If it is, ask them to initiate an appeal, or appeal the denial. Either wording should work. Often, reps can’t offer an appeal, but if you ask, then they’ll get one started for you. This will start a review of the denial, which means that the insurance company will review the denial again, including asking for records and/or a conversation with your doctor. They might not change their mind, but it’s always worth a try. If you’ve already tried that, reach out to your state Department of Health or Department of Financial Services, or your elected representatives (state or federal level). Social media and traditional media pressure often work wonders, too.

What can I include in my appeal to boost my chances of a favorable outcome? 

Try and mirror the denial language, if at all possible. Don’t make stuff up, but do talk about what you’ve done that might help meet their criteria for approval. If the denial is because you didn’t do formal physical therapy during a pandemic, but you did do a home exercise program, mention that. Tell them how you got to the point of having this procedure requested. Highlight how the condition being treated is impacting your activities of daily living (dressing yourself, toileting/hygiene, mobility, eating, etc.) or employment and how the test or treatment helps address those problems. Tug at their heartstrings.

What’s the deal with insurers denying things they say aren’t medical necessary when they clearly are?

Medical practitioners who work for the insurance company look at a procedure or service that a doctor wants to do to treat a patient, and decide if the service and the treatment leading up to it meet the criteria for the insurance company to consider it “medically necessary.” Now, “medically necessary” doesn’t always mean “no, you don’t need this procedure.” Sometimes – even often – it means “there were other treatments that could have done the same thing that you haven’t tried yet, that are less invasive and cost less, why don’t you give those a try first?” If a prior authorization is denied, the patient and/or the provider can challenge that denial, and it will be reviewed again by a different reviewer. There’s a whole department dedicated to these re-reviews, and lots of regulations around how they do what they do.

Case in point: I suffered a serious injury a couple of years ago, and the doctors immediately went “yeah, you need surgery.” The prior auth was denied because we didn’t do physical therapy first – which can sometimes be useful in treating the symptoms I had. But when a jelly donut pops, no amount of PT is going to put the jelly back in. You just gotta clean it up. So I sent in an appeal to challenge the denial, which basically consisted of “look at this picture from my MRI and tell me how PT is going to help that.” Within literal hours, the authorization was granted and my surgery was back on the books.

What if I went to the ER but my claim was denied because insurance said my condition wasn’t actually an emergency?

See if your state has something called an Emergency Services or Prudent Layperson mandate (law) that you can appeal the decision under. These basically say that if a normal person without any medical training could reasonably believe that they were in serious danger of death or disfigurement if they didn’t get emergency medical care, then seeking emergency medical care is appropriate and should be covered. In other words, if you have severe chest pain, then you go to the ER. It’s not up to you to tell the difference between a heart attack and severe, unexpected heartburn (actual claim I saw…).

Can I ask my insurance company to call a provider for me?

You betcha! If your insurance is through certain national franchises with names like Purple Star And Purple Square, there might be rules about how they can get in touch with providers outside of their servicing area, but there are ways around those restrictions.

What can I ask my insurance company to call a provider about? 

Authorizations, referrals, is the provider in network, and, my absolute favorite, if you don’t understand a bill, if they’re billing you incorrectly or if the insurance company is reprocessing or reviewing a claim. If you don’t understand a bill, a rep can call the billing office and get clarification – I LOVE translating billing-speak for people. If the provider is billing you incorrectly, the insurance company can put a lot more weight behind enforcing billing rules than you as an individual can, and was one of my favorite things to do. If the insurance company is reviewing or reprocessing a claim, at the very least they can ask the provider to put your account on hold until the reprocessing is done. They can also ask the provider to put your account on hold for a coding or billing review, which can buy you some time.

What information will my insurance company need if i need them to call a provider for me about a bill? 

They’ll need the name of the entity sending the bill, the invoice or account number, the amount of the bill, the date or dates of service, and the billing phone number from the bill at a minimum. They’ll probably also see if you remember who performed the service and what the service was.

What if I can’t afford my medical bill, but it’s correct? 

Ugh, I hate that this is a thing. In this case, you can probably work out a payment plan with your provider. If you want, you can ask your insurance company to call on your behalf and see what options are available before your call the provider yourself, or to do a conference call with the provider’s billing office to help translate billing- speak for you.

Why won’t the insurance company tell me things about my spouse/adult child’s claims?

This is where HIPAA comes into play. Subscribers (the person who gets the policy through their job) will still get all explanations of benefits and monthly health summaries, but once someone turns 18, the insurance company can’t give out any information about policy use without authorization. Some specific categories of treatments or illnesses can also have tighter restrictions and require a specific authorization. Talk to your benefit coordinator or insurance company and find out how to get that authorization on file – sometimes you have to fill out a paper form, and sometimes you can do it through an online account.

I have so many doctors that I have trouble keeping track of them. Can my insurance company help at all?

Possibly. Call in and ask about medical care management or case management services. Your employer’s EAP (if they have one) may also have case management services available.

Anything else people should know?

The insurance company has a contract with lots of doctors that defines how much they’ll pay for each service. Any doctor with a contract is considered “In Network.” This contract does a lot, but there are two pieces directly applicable to consumers. First, it outlines what services the company will reimburse a provider for. For example, an orthopedist won’t get paid for doing heart surgery, because that’s not something they’re supposed to be doing. The second thing the contract does is set the maximum that the medical provider will be paid for a service, between the insurance company payment and any patient cost share. This is the “Allowed Amount.” Patient cost share (copay, coinsurance, deductible) will never exceed the allowed amount – you’ll never pay more than that contracted rate, no matter what the provider charges. We see stories in the news all the time about hospitals charging $40 for a tongue depressor, which is obviously absurd, but the insurance company can turn around and say “hahahaha no, you’re getting paid a penny for that, nice try,” and the hospital has to write off the $39.99 – they don’t get to bill the patient, because of that contract with the insurance company. If you go to a provider who doesn’t have a contract with your insurance company, that’s considered “Out of Network” and there’s nothing protecting you from the provider billing you for their full charged amount. When possible, stay in network. That protection is what you’re paying for. (If you can’t find an in-network doctor to do what you need, ask your insurance company for an exception.)

A common misconception when it comes to deductible plans is that if the insurance company doesn’t pay for something, it’s not covered, when often the whole allowed amount just went to deductible. When this happens, the patient has to pay the entire allowed amount, but there is still coverage in that the insurance policy limits how much a provider can bill a patient.

Insurance companies also offer lots of services outside of just the provider networks and benefits contracts. There are often discount programs for things that aren’t specifically medical care, but support your overall health. There also might be case management programs available, to help people with complex medical issues navigate the insurance and medical labyrinth. If all avenues with the insurance company fail, outside entities that can help are patient advocacy groups, your state department of health, the attorney general, and your state and federal representatives and senators. Media and popular pressure is also a lever you can pull.

Also, I can guarantee that the vast majority of phone reps you talk to will want to help you. They know that health insurance is at the intersection of people’s money and health, and is a really confusing, scary, and overwhelming place to be. My fondest memories of being on the phones are of times that I really helped a consumer, whether it was helping a piece of their policy make sense, getting a provider billing office off their back, or reducing a bill for them. Truly, the reps are there to help you and will do their absolute best for you. Sometimes their hands are tied, but most of the time there’s something that can be done.

{ 479 comments… read them below }

  1. Insurance Q&A*

    Hi peeps! I’ll be floating around the comments for a few hours, so feel free to ask questions, ask for clarification, etc.

    Just PLEASE, I beg you, don’t go in on the “US Healthcare Is Monstrous.” We know. We allllllll know.

    Happy Wednesday!

    1. Monty & Millie's Mom*

      No questions, just a HUGE THANK YOU! I worked in medical billing for about 10 years, and it was basically “learn as I go”. So while I’m familiar with pretty much all the info you provided here, I know that SO MANY people don’t know anything and are either too afraid to ask, or don’t know who or what to ask, or just try to bluff their way through things! This lays things out really clearly, and while of course people with a lot of doctors and comorbitities and things will maybe have a trickier time, you laid everything out really clearly, and I appreciate that! You’re a fabulous human and I wish you days and days of sunshine and happiness!

    2. COBOL Dinosaur*

      Hi! I work in IT at a major health insurance company and the Customer Service Reps at our company are AWESOME! I am so thankful every time that I need to call in for help and so glad they are there for our members. They really are there to help!

    3. Sharkie*

      *waves in costumer service rep*

      Also I have something else to add. Sometimes if EAP is not available, there might be some no cost sessions built into your plan so it doesn’t hurt to ask.

      1. Insurance Q&A*

        Yes! Literally, it never hurts to ask – as long as you do it using your inside voice :)

        1. Sharkie*

          Exactly. I know everyone one my team will move mountains for callers that are nice on the phone.

    4. KTV123*

      Thank you, this is fabulous!! I work in health insurance and we are a non profit and try to do the right thing while still managing finances.
      One thing to add about appeals- I have been on appeals committees and tugging at heart strings is great- but we don’t go off of that. We have to go by policy. I frequently hear “if you do x (that is not a covered benefit), it is cheaper than do this (covered benefit) that’s fine but we truly aren’t looking at that- we want to know why your case is truly justified as being able to go outside policy (ie there TRULY is no other provider in network who can do what your Out of network doc can do). Just a tip! Good luck out there.

      1. Insurance Q&A*

        Oh I know, but tugging on heartstrings has helped me get SO MUCH relevant information out of people about ADLs, prior treatment history, etc, that they wouldn’t otherwise have thought of. I’m all for tricking people into helping themselves ;)

        1. OhNo*

          I was just thinking the same thing! Folks might not be able to justify a decision based on their feelings, but humans are often more willing to go the extra mile and find a loophole if they are emotionally invested. It definitely works on me, though I’m not in a healthcare-related field.

    5. Charlotte Lucas*

      I’d like to add that a lot of this advice also applies if you get coverage through a government health benefit. But there can be additional rules (often to protect you), so keep that in mind.

      1. Insurance Q&A*

        Yeah, I (am so glad that I) don’t train the Government policies on top of this – my head would never stop spinning. But because I don’t have that training, I’m not entirely comfortable advising on it because of all those regs I might not know about. Know what you don’t know, and all that :)

        1. Anon Supervisor*

          A lot of times, government financed policies (Medicare and Medicaid) are a bit more easy to navigate because all payment and benefit policies must be available to all. Billing and payment policies are heavily determined by Correct Coding guidelines that push liability to the provider. The only reason you should be getting a bill as a patient is if you got a service that is categorically NOT COVERED per your policy (think routine vaccines outside of the flu and pneumonia vaccine for Medicare) or you have a Medicaid plan with a spend down (i.e. deductible).

      2. Mme Pince*

        I had exactly the same thing happen and spent ages reading about what was covered and trying to figure out why they might not have covered it. I eventually called the provider after not getting anywhere with the insurance company and they said specifically lipid panels for people under a certain age are just written off if insurance won’t cover them but their system won’t do it automatically yet.

    6. pony up*

      So my insurance company is not covering the cost of lab tests that were done at my annual physical. I thought that the ACA required that preventative care be covered fully, at no direct cost to the patient? Why am I paying 100+ bucks to check my cholesterol? I thought that was the point of a physical.

      So am I missing something, or is my insurance company trying to pull a fast one?

      1. StarHunter*

        This use to happen to me every year. My PA was coding the lab work incorrectly. It needs to be coded as part of your annual check-up, not diagnostic. The Dr needs to resubmit the paperwork with the proper coding to the billing department. So it’s worth a phone call to your provider to try and get it straightened out. And at your next physical remind your Dr to code the lab work properly.

        1. Insurance Q&A*

          Yeah, it depends – certain tests are covered in full under the ACA, and others aren’t. It also can come down to the coding on the tests that are covered. The ACA made a lot of things better, but it’s still super complex.

          Don’t be afraid to call your insurance company and have them ask your doctors for a coding review “because we thought this should be covered under ACA but it looks like the coding is a little bit off.” Insurance can’t tell doctors how to bill, but they sure can drop hints!

      2. Anon Supervisor*

        Make sure your labs have a screening diagnosis attached in order to be covered. Your insurance company may be able to help.

      3. KTV123*

        It is likely because it is not coded correctly, like not coded as preventative. I’d for sure call your insurance company and push on it. It could have also been sent to an out of network lab.

      4. Mme Pince*

        I accidentally replied to the wrong comment above.

        I had exactly the same thing happen and spent ages reading about what was covered and trying to figure out why they might not have covered it. I eventually called the provider after not getting anywhere with the insurance company and they said specifically lipid panels for people under a certain age are just written off if insurance won’t cover them but their system won’t do it automatically yet.

    7. Bob*

      Thank you so much for doing this! I have insurance through a ‘purple square’ company and was hoping you could provide some advice on how to appeal a denial for a genetic test deemed “investigative” and therefore not covered. The issue is it’s a blood test looking for a certain marker so it’s not clear cut as providing a MRI. My doctor has already tried to reappeal the denial with no luck.

      Also I had met my deductible at the time of the denial, but my insurance informed me that if I proceed with getting the test without the pre-authorization, it would be considered “out-of-network” and so I wouldn’t be able to cash pay the contract rate.

      1. Insurance Q&A*

        Oh, yeah, genetic testing is tough… So if your doctor has already tried with no luck, I would try an appeal based on how your life is currently affected, and how the test could impact treatment and improve your quality of life. It’s not a guarantee, of course, and they still may come back and say no, but “Symptoms are limiting/affecting my life in X, Y, Z ways. I have attempted procedure/treatment/test A, B, C. This test will determine if the cause is Llamas or Cows, which will then help us tailor treatment correctly so that I don’t have X, Y, and Z limits any longer.”

      2. Loosey Goosey*

        I don’t know if this applies to you, but I just did genetic testing through LabCorp, and it was not covered by insurance at all. I talked to the billing department, and they have a program where you complete a survey in exchange for a vastly reduced out-of-pocket cost. It’s worth telling the testing company you will be paying OOP and seeing if they can do anything for you.

        1. Genetics Anon*

          A lot of genetics companies will give you a cheaper cash pay price than the price they bill insurance. Though this is largely dependent on the company. Even if approved through insurance this cash pay price can be cheaper than the patient responsibility ( if for example patient has high deductible) or the cash pay price can be exponentially higher than what you’d pay with insurance

      3. Genetics Anon*

        So I work for genetics providers, MDs, and while my job isn’t in billing I work hands on with our billing coordinator. I have also filed prior auths and fought for patients to have those prior auth approved / expedited etc. At my job we really don’t encourage patients to submit their own appeals we have significantly more luck with provider appeals. Usually insurance companies (we work with many including purple star and purple square ) offer at least 2 options for providers. A written appeal and a P2P ( peer to peer ) appeal. We do almost exclusively peer to peer appeals and have significant luck with them. I would ask your provider which type of appeal they did and if they haven’t done a peer to peer to do so. Peer to peers are doctors talking ( frequently arguing ) back and forth. A lot of times doctors can do both type of appeals. Depending on the type of genetic testing ( is this one gene or multi gene) there may be ways to resubmit the testing in a different way in regards to coding. Unfortunately many insurance companies and reps are not at all informed in regards to genetics ( we have a lot of issues with this ) but some are better if they have a dedicated genetics department / a genetics professional involved. Hope this helps !

    8. LorettaLynn*

      Thank you so much in advance! Could you please advise how to appeal a denial for a genetic marker test? It’s not as clear cut as providing an MRI image, and the insurance has previously deemed this test as “investigative” and therefore not covered. My doctor tried to appeal the denial with no luck.

      Also my insurance told me after the denial that even though I had met my deductible for the year, without the insurance’s pre-authorization for the test, I would not be eligible to receive the contracted rate so it’s not like I even had the realistic option to come out of pocket for it.

      1. Insurance Q&A*

        Hi Loretta! I just answered a very similar question for Bob, so here’s what I said:
        Oh, yeah, genetic testing is tough… So if your doctor has already tried with no luck, I would try an appeal based on how your life is currently affected, and how the test could impact treatment and improve your quality of life. It’s not a guarantee, of course, and they still may come back and say no, but “Symptoms are limiting/affecting my life in X, Y, Z ways. I have attempted procedure/treatment/test A, B, C. This test will determine if the cause is Llamas or Cows, which will then help us tailor treatment correctly so that I don’t have X, Y, and Z limits any longer.

        Good luck!

        1. LorettaLynn*

          You rock! Alison rocks for having hosting you on her page! Both of you please know deep in your hearts that you are doing good things for people by offering a space for forums such as this.

          1. DKMA*

            FYI – we had genetic testing done by the hospital for our kids and it was rejected based on them doing too many tests at once. We appealed to the hospital about it, and the hospital ended up just dropping the $1500 charge. I’m still confused on that one. We talked twice, the second time they told us they were processing on their end and not to call back, so we documented interactions and never called again and never got another bill.

    9. AnonMurphy*

      As a fellow (former) CSA for a carrier, this is an INCREDIBLE summation. Thanks for sharing!

    10. AndersonDarling*

      I’ve heard that an appeal will automatically be denied x number of times. Doctors have told me to be prepared for every appeal to be denied, but keep submitting it until the “final” appeal because that is when a real person actually reviews it. And to also be prepared for the “Nope we didn’t receive that fax” even though the documents were faxed a dozen times.
      Is any of that true? Or maybe it’s true at certain insurance companies but not at all of them.

      1. Insurance Q&A*

        It might be just one particular insurance company – it’s not the case where I work. It sounds like way too much work for everyone involved, and I’m so sorry you have to deal with it.

        the “Nope, didn’t get the fax” is highly suspect, though, just to validate that. Sounds like that company needs an efficiency overhaul.

        1. AndersonDarling*

          Thank you for putting a human face on the situation! I want to believe that everyone I talk to really wants to help, but then I wonder if they are just part of the big machine and the overlord running the machine just wants me to give up.

      2. AnonoDoc*

        After too many “we didn’t receive it”s and confirmations of the fax # being the same as on the fax confirmations, I must admit that I once made a bunch of copies of the document in question, and stood by the fax machine for an hour sending hundreds of copies while I finished up notes.

        Yeah, they somehow got those.

        And don’t get me started on “the doctor coded it wrong”. No, I used the honest code, you just chose not to pay.

        1. Insurance Q&A*

          Yeah, those two phrases – “we never got the records” and “the doctor coded it wrong” – make me see red. The company got it, if one would look in all the places it could be… and providers don’t usually bill incorrectly – there’s no reason to. The implication is that the provider is committing fraud, rather than the honest answer that the insurance company has an issure with the coding. Aaarrgghhhh

          Sorry, i know this wasn’t terribly helpful, but I wanted to validate what you’re saying.

      3. Anon Supervisor*

        This is most likely illegal now, as most insurance policies are ERISA plans provided through employers and have a dispute process that they have to honor if you are submitting appeals/reconsiderations in good faith. Check with your Attorney General’s office if you suspect appeals for payment are being denied without merit.

    11. Anonariffic*

      Just wanted to jump in and say thank you for this article and what you do!

      I had a covid test late last year where the clinic sent me a bill for the full cost of the test with a note that my insurance had covered their portion and the remaining cost was my responsibility. I called my insurance and the phone rep verified that not only should my test have been fully covered, but the clinic hadn’t even bothered submitting the claim before billing me. It took a couple weeks to sort out because the clinic also didn’t like answering phones or returning messages, but the insurance reps were 100% clear with me from the start that I shouldn’t be spending a dime and that they would take care of things.

      1. Ooh La La*

        Seconding! This is all such great advice, and definitely, when in doubt, call and ask. I’ve had instances where I was billed directly despite having insurance, or I was balance-billed despite that not being allowed by the policy, or the insurance incorrectly denied claims because of their own administrative error. It’s time-consuming, annoying, and can be complicated, but it saves you a lot of money when you catch errors.

      2. Anon Supervisor*

        Balance billing for COVID testing may also be illegal under the CARES act. Never pay for a COVID test related bill until you speak with your insurance company. Billing for these tests are super-complex and highly dependent on the coding.

    12. Kristina*

      Just a former Medicaid CSR popping into to say YES! to all of this. FAR too many people have no idea they have the right to appeal, appeal, appeal!

  2. middle name danger*

    I don’t know if your helpful reader would be willing to answer more questions, but: what’s the deal with plans that don’t allow you to add a spouse if that spouse is offered coverage through their own job? And is there a way around that?

    My wife and I have almost identical coverage, but both of us on her plan would cost the same amount monthly as just me on my own plan.

    1. I Need Coffee*

      This is on the employer as they approve plan designs and costs, not the insurer. It is her employer encouraging you to shift the cost of subsidizing your health care to your own employer.

        1. devtoo*

          we had a lot of jokes at work about this barbaric-sounding term when my employer added the spousal carve out this year

    2. Insurance Q&A*

      Hi Middle Name Danger!

      This sounds like a total pain. Ugh.

      My first question would be if this rule comes from the insurance company or the employer. Both start with a conversation with your benefits coordinator in HR. If it’s from the insurance company, the benefits coordinator can contact the insurance company and ask them to make an exception – insurance companies like to keep employers happy, since that’s where the bulk of their business is. If it’s from your employer and HR doesn’t seem receptive to making an exception, you can call the insurance company and see if they can put their sales department to work. Sales can contact your group and “ask for clarification” as a way to get you an answer or get a change made (whether the change is just for you, or is at a larger level).

      Hope this helps!

    3. BRR*

      I would guess it’s for your employer to save money. I’d be curious to compare what your company and your spouse’s company contribute to as their part of the premiums.

      1. middle name danger*

        My company is a lot smaller than hers (5000+ vs probably less than 100) so I’m guessing her company gets a better price break which results in cheaper costs to the employees.

        I will definitely have her follow up to see if the spousal carve out is from the employer or insurance company! Thanks!

    4. ABK*

      Likely coming from your employer. Employers generally pay a large portion of the premiums for individuals in their group. Some of them also take on some of the “risk” of insuring that group, one example if this are deals where the insurance company will pay up to a certain amount per year in claims for the group, then the employer is on the hook for the rest. So your employer is obligated to cover YOU, but is less inclined to cover your spouse since at the very least it increases their premium burden and might also put them at extra risk down the road. Seems like there’s a loophole where they don’t have to provide coverage if your spouse has access elsewhere. Seems like ACA should have put an end to that, but alas.

      1. Marple*

        I believe the ACA was what triggered the end of spousal insurance. It seems like that’s the time my employer stopped offering it around the time the ACA was enacted. Spousal exclusions might just be a result of a long trend of rising health care costs, though.

        1. Anon Supervisor*

          No, it’s not really ACA related, it’s really just based on your employer. My employer has had the spouse carve out for the past 12 years or so. Lots of insurance plans are self-funded and claims cut into the bottom line of the company. If your spouse has access to coverage under their employer, and that employer pays at least 50% of the premium, most employers don’t want the added expense of adult defendants.

    5. Anon Supervisor*

      This is an employer stipulation. My work does not allow adult dependent coverage (even if it’s secondary coverage) if your spouse has the option for coverage where more than 50% of the monthly premium is paid by their own employer. It’s a cost-saving measure to keep employee premiums down.

    6. Ben Marcus Consulting*

      Plan Admin here, the most likely reason is cost. Employers cover a portion of the premiums for you, your spouse, and your children (depending on what level of coverage you sign up for). If your spouse is able to obtain coverage through their employer, then that’s premium dollars that could be diverted elsewhere.

      Depending on a number of factors, the usual minimum premium contribution for employees is 50%. The contribution for family and spouse depends on the employers goals. I do 75%.

      If you’re curious about how much your employer spends on your premiums, you could ask for a Total Compensation Statement. Assuming a reasonably competent payroll processor, this will include base pay, contingent pay, paid time off, benefits contributions, and payroll taxes.

  3. Cat Lover*

    “A common misconception when it comes to deductible plans is that if the insurance company doesn’t pay for something, it’s not covered, when often the whole allowed amount just went to deductible. When this happens, the patient has to pay the entire allowed amount, but there is still coverage in that the insurance policy limits how much a provider can bill a patient.”

    YES, YES, YES!!! I work at a doctor’s office and I have to explain this to patients all the time. I’m sorry you have a high deductible and I’m sorry that the allowed amount is high, but we are in network. If we were out of network, you would be paying a LOT more.

    1. Ya Girl*

      Right! If your plan has a $8K deductible there’s not much a provider can do for you!

      1. Cat Lover*

        Thankfully most people with high deductible PPO plans have some sort of FSA or HSA account. But it is still a shock to some people, especially at the beginning of the year.

        1. noahwynn*

          A former employer had an HRA account. That was the best thing ever. I think employees paid the first $500 of the deductible, then the HRA paid the next $500, then employees paid $1500, then the HRA paid the rest.

          So our effective deductible was only $2000, even though the actual was $5000. It was a way for the company to reduce premium costs and also partially self-insure.

        2. Lyudie*

          Last year was my first year with an HSA…I was so annoyed that I had a high deductible and still had to pay so much for meds…I didn’t realize you’re meant to pay that kind of stuff out of the HSA. I was treating it like a second savings just for health stuff for the future. Oops haha. But yeah it was definitely an adjustment after years on my husband’s plan. I’m constantly amused by the things that are and are not reimbursable under the HRA/HSA plans.

          1. Abcde*

            The Money Guy Show (on YouTube) did a segment on HSA’s a couple of years ago. IIRC there is no time limit for when you can “bill your HSA”. If the HSA is established in April 2021, the expense is incurred in May 2021, you are welcome to wait with reimbursing yourself from your HSA until 2030 – by which time you have hopefully incurred 9 years of compound interest on the sum in your HSA.

            The HSA is like their favourite thing, it’s got a ton of tax advantages.

            Worth checking out if you’re interested.

            1. Lyudie*

              Thanks for the tip! I am not savvy on this stuff at all so that sounds like a great resource (and this post reminds me I need to adjust my contributions so the IRS doesn’t yell at me again).

          2. JustaTech*

            The first year my company offered the high-deductible/HSA plan they kept talking about how much money “we” would save by using this plan, until I asked if the difference in premium would be put in the HSA for us form the company. “No?” “So the *company* is saving money, but the individual is not, and if you have a large medical expense at the beginning of the year when the HSA is empty you’re hosed, correct?” “Uh, yes?”

            No one picked the HD/HSA that year, and the next year they changed it so if you chose that the company would put the premium difference (~$2000) in the HSA for you at the beginning of the year. Then some people chose that plan.

    2. 3DogNight*

      **When this happens, the patient has to pay the entire allowed amount, but there is still coverage in that the insurance policy limits how much a provider can bill a patient.**
      This part, I had no idea! Thank you for calling this out, as I have some procedures coming up, and am a little nervous about the amounts! Thank you!

      1. Insurance Q&A*

        You’re welcome! Realistically speaking, look at the Maximum Out Of Pocket amount on your policy. That is the MOST you will pay for in-network services for the year. You cannot pay more than that. So that’s your (still very stressful) ceiling.

      2. Sharkie*

        Ask for the procedure code! Us reps can look it up for you and give you ball park costs.

      3. Anon Supervisor*

        Check to see if you have an out-of-pocket maximum that is over the amount of your deductible. My husband used to have an 80%/20% plan that had a $1600 deductible but a $3000 out of pocket max. So, once he met the $1600 deductible, his insurance would pay 80% and he would have to pay 20% of any additional claims until he reached $3000 out of pocket. His premium was super high too. It was a crappy plan.

        1. Snailing*

          I can’t speak to the premium, because that would vary based on the demographics and size of his group, but while it’s certainly not nothing, a $1600 deductible and $3000 out of pocket is a mid-range is not slightly better than midrange plan. I work at a benefits broker (basically we help aggregate plans for employers, help with questions/enrollments/changes/etc but work with all insurance carriers), and I mainly see plans with $3000 and greater deductibles with $6000+ max out of pocket. We do have some unicorns with a $500 deductible or even no deductible… a girl can dream, right?

          1. Anon Supervisor*

            Yeah, I have a unicorn plan with a $500 deductible, though I do have a restricted network. His premium was twice what I paid, which is why I considered his plan crappy (although it’s probably on par with the market).

  4. Lana Kane*

    This is a bookmarkable (it’s a word) post! I’m in healthcare, and I spent years on the insurance side of a major hospital. Insurance in the US is so complex, and the best part of my job was helping people navigate all of this because they tended to be very grateful for the guidance. Insurance is very intimidating! Thank you to the OP for putting this together, and Alison for giving it a platform.

  5. Ya Girl*

    Love this! I work in a practice handling prior authorizations for a specific type of surgery. If you are having a major procedure and you’re confused about costs there is almost certainly someone like me working with your doctor who can answer the vast majority of your questions and help explain your policy so there are no surprises! A lot of my job is demystifying patients’ insurance for them and making sure that they are getting the absolute most out of their policy.

    1. Insurance Q&A*

      Yep, one of the things I wanted to do with this was kind of show that providers and insurance companies are made up of actual people who are trying to help patients get the best outcome possible within our current system. I’m so glad you do the work you do!

    2. Dana Lynne*

      I sure wish I had had you when my doctor ordered an MRI with dye to try to figure out why something was happening to me and my insurance would not pay for it even though we tried to follow the rules for prior authorization. I got nowhere on the phone with my insurance company, and nowhere with the doctor’s office afterward. At one point the doctor’s employee burst into tears and told me to quit bothering them.

      I ended up paying for the whole thing myself and never did get an explanation from anyone about why it all happened.

      I never went back to that particular doctor.

  6. Pikachu*

    This is very helpful!

    Could this possibly include something about Explanation of Benefits statements? They aren’t bills, but can be pretty anxiety-inducing when they show up in the mail suggesting you might owe a certain amount based on billing codes you may or may not even understand.

    1. Cat Lover*

      EOBs are just that- your insurance company sending you the breakdown of your medical charges.

      1. Pikachu*

        Right, but when they say “amount you may owe,” that amount may or may not even be real based on all these other factors. What should a person do with an EOB if the charges don’t align to the benefits as outlined in their policy documents? Do you wait for a bill to show up and then start trying to figure it out?

        1. Insurance Q&A*

          Hi Pikachu! Explanations of Benefits are what you get every time your doctor submits a claim to insurance. Your insurance company sends you a breakdown of that claim to tell you how the claim processed, how much insurance paid, and how much the provider is allowed to bill you. The provider gets their own copy, telling them basically the same information – especially the max they can bill you. You can then make sure that the provider is only billing you what they’re allowed to, whenever they do send you the bill.

          1. New Job So Much Better*

            Building on Pikachu’s question– yesterday I got a revised EOB for something approved and covered last fall. And saying I owe it all! The vendor is looking into it, says it happens all the times to make the vendor “prove” they had the proper documentation. Do you see that a lot?

            1. Insurance Q&A*

              I do, unfortunately. I’m so sorry you’re dealing with this. This is the explanation (not my approval of the process):

              The claim comes in, and processes, and you get your EOB. Then the insurance company does what’s called a retrospective review, where they look at claims that have already finalized to make sure they’re paying correctly. Sometimes claims come through this just fine, sometimes they actually get changed in your favor, and sometimes the company goes “wait, we need more documentation on this,” so they deny it to get everyone’s attention. Once they get the documentation, often the claim is readjusted to go back to how it was in the beginning before all this happened, but it definitely can cause major stress in the meantime.

              1. Cat Lover*

                I’ve had insurances retract payments for MONTHS due to patients having a lapse in coverage (or failing to tell the provider that they got a new insurance and therefore we were billing the wrong people). Often, we (the provider) needs info from the patient, or the insurance sent some questionnaire out that the patient never did, and they deny based on that. If we cannot get in contact with them, we set all claims to “bill patient” to get their attention.

                1. Insurance Q&A*

                  Yep, sometimes “bill the patient” really means “hey, we need more info and we’re not getting it, so we need to get your attention somehow or other and bills are a proven method!”

                  I don’t like it, but I get it…

    2. Blackcat*

      I’ve also found them really helpful!
      I had to switch away from a practice that consistently billed far more than what was stated in the EOB. They’d get payment from insurance then ask for *full* payment from me as well.
      I reported them to my state because that’s illegal in addition to obnoxious.

    3. Elizabeth Bennet*

      Pikachu: Remember this – the EOB is also a way to track how much is being counted toward your deductible, regardless of whether you’ve paid it. Think of it as a “heads up, this bill is coming.” If that is anxiety inducing, remember that you can likely setup payment plans with the provider, or negotiate for a smaller lump sum payment. My husband does this all the time with our bills – just flat out tells them, “I have $250 I can use to pay my medical bills, and I have of stack of bills for $1200 right now. Your bill for $350 is on top, but if you can’t take the $250 for the whole bill, I’ll put your bill on the bottom.” More often than not, the provider’s office will take the lump sum. But be honest about it. My husband is honest about how much money we have to pay medical bills any given month when he calls, and sometimes he saves some serious money.

      Also, look up your state’s statute of limitations for billing by medical providers. The statute of limitations in my state is three years (maybe it’s a nationwide US limit?), so if you get a new bill for services performed a long time ago, know where the line is drawn on whether you’re obligated to pay it.

  7. Frenchie Too*

    This is somewhat related, I read that if you get a very high hospital bill you can call the hospital and ask for an itemized statement. They don’t always want to expose how much they are charging for small things, such as bandaids or analgesics, so they reduce the amount.
    I have not done this, so can’t say if it works. But, it’s worth a shot.

      1. Ask a Manager* Post author

        It’s not off-topic! Also, I did it last year when I mangled my finger in a blender. (That’s a very expensive thing to do, it turns out!) I found out they’d charged me for something that I hadn’t actually received.

        1. Insurance Q&A*

          I… Don’t even want to know how that happened. Owwww.

          I know people who have had similar very expensive hand injuries, and the itemized bills really do help keep providers honest.

          Not to say that they bill maliciously, just that human error is a thing, etc…

        2. EarthBound*

          Hey, I mangled my finger in a blender, too (it was about 11 years ago). I’ve never heard of anyone else doing this.

        3. Blackcat*

          Yes, this has happened with about half of my major medical events. I’ve regularly been charged for medications I never received or procedures not done, including a CT scan (which was $$$. I got an… xray. a plain, old x-ray and they billed a CT!).

    1. NotSoAnon*

      Our company’s benefits coordinator explicitly tells us at our annual meeting to do this! He said he does it for all of his and has had great success at reducing some of his bills.

    2. Weekend Please*

      Another thing you can do is call and ask if they offer a discount for paying it all off right away instead of going on a a payment plan. When I was hospitalized they offered me a 10% discount for paying it all when I called them instead of going on a payment plan.

    3. Insurance Q&A*

      I completely agree with this! Hospitals in some states are required to post their fees in a public location, but as we know, “public” doesn’t always mean “easy to find.”

      1. ExtraInfo*

        Actually, a federal law that went into effect on 1/1/21 requires all hospitals to “provide clear, accessible pricing information online about the items and services they provide…”. If you’re on a hospital website and can’t find that information, there’s a way to report that as a violation. Google “federal price transparency” for more information.

      1. misspiggy*

        I hope this isn’t too far off topic, but isn’t there then a penalty for overcharging/miscalculating a bill?

    4. S*

      Yes! I did this when my oldest was born and found that I was charged $1500 for an epidural. 9 years later, I have still never had an epidural. (Giant needles are terrifying.)

      I also received a check from the hospital nearly 3 years later for “overpayment.”

  8. InsurancePro*

    I’m an expert on health insurance (both professionally and personally) and to be honest, I’m confused by a lot of these answers. The most glaring issue I see if the mention of “deductible plans” and “copay plans.” All plans have deductibles. After you reach your deductible, some plans have co-insurance payments (when you pay a fixed percentage of the allowable amount) and some have fixed co-pays (when you pay a set fee per visit or procedure).

    Out of Network does not necessarily mean that you are on the hook for balance billing. For example, my plan covers 80% for specialist visits. That means I am billed 20% of the allowable amount and the insurance company pays the other 80%. When I see an out-of-network provider, these percentages change from 80/20 to 70/30.

    1. Insurance Q&A*

      Not all plans have deductibles. All have out of pocket maxes, after which everything is covered in full.

    2. Cat Lover*

      Depends on specialties as well. I work in a physical therapy office and for a lot of insurances, PT doesn’t go towards a deductible, it’s a flat copay. Some are deductible then co-insurance.

      OON also varies a lot. Some it’s higher percentages, some we can’t bill at all and the patient will be on the hook for all of it.

      1. InsurancePro*

        Agreed. It’s all dependent on your plan. The Expert wrote that “If you go to a provider who doesn’t have a contract with your insurance company, that’s considered “Out of Network” and there’s nothing protecting you from the provider billing you for their full charged amount.” This implies that OON means major bills, when it’s quite a bit more complex than that.

        1. Insurance Q&A*

          I didn’t have space to include All The Details, you’re right. However, nothing I said implied major bills – simply that there is no protection from the insurance company for being billed over the allowed amount.

          1. Ben Marcus Consulting*

            I think InsurancePro means that your phrasing indicates that in-network is the only way to control costs, and many times that is true. However, out-of-network offers more flexibility in the payment arrangement because there are no contracts to follow, which can mean greater savings.

            This concept is doubled down when you use a cash-only service provider. You could join a membership-based or cash-for-fee provider like Forward Medical, and the submit that to your carrier for reimbursement.

            There’s a surgery center in Oklahoma that has a flat cash-fee. While they are happy to bill for you, you can opt to take the cash fee and submit for coverage yourself. You might spend more, you probably will spend less.

        2. Anon Supervisor*

          Also, your plan may have some out of network benefits for certain procedures.

        3. Kyrielle*

          I had to go OON for one service, and insurance paid the customary/allowable amount under their plan. Because they were not in network and didn’t have agreements, I had to pay the rest of what they charged rather than just my coinsurance, but it still covered more than half of it.

    3. ThatGirl*

      I know this has been answered, but no, not all plans have deductibles. That said, what I see most often is a standard PPO plan and a high-deductible plan – so one has, say, a $1,000 deductible with co-pays on things like doctor’s visits and prescriptions, and the other has a $2000 deductible where you pay the allowed amount for everything, often with an HSA attached. But when my husband first started at his current job, they offered an HMO plan that had no deductible, very minimal copays, but a limited network and you needed referrals for everything.

    4. Liz*

      I’m *not* an insurance expert (though I do know that not all plans have deductibles) and I understood the shorthand for “deductible plans” and “co-pay plans.” I’m confused on what the issue is?

      1. InsurancePro*

        it’s true that about 16% of employer-sponsored plans don’t have deductibles (according to the KFF employer insurance survey, which isn’t really generalizable, but I digress). It’s not clear to me whether the author meant high-deductible plans here? co-pays (and co-insurance) and high-deductible plans are not mutually exclusive components of a health insurance plan.

        1. Insurance Q&A*

          I didn’t have the space for a full breakdown of all plan types and permutations, and I’m using vacation time to do this. Please give this a rest.

        2. Brooks Brothers Stan*

          It sounds less like you don’t understand and more like you want wave your own credentials under the guise of being technically correct. You seem to be the only person getting this confused, and granting you the grace that this is a field you know a lot about then you should also realize that this isn’t directed at your level.

          If you want to get into an in-depth discussion about the exact technicalities and definitions of plans at an expert level, I’m sure multiple think tanks in the DC and NYC area are running an event soon. They’d probably enjoy having you on the panel.

          1. Lana Kane*

            Bureaucrat Conrad, you are technically correct. The best kind of correct. I hereby promote you to grade 37.

  9. CatCat*

    One thing some of my loved ones have a hard time understanding is the explanation of benefits paper that comes in the mail. They get confused when it says it’s not a bill, but also it looks like a bill. I am sure others find these papers confusing.

    1. CatCat*

      Sorry, my question is are there any good links that explain the EOB in VERY basic terms?

      1. InsurancePro*

        Your insurance company’s website should have a very basic and comprehensive guide to reading an EOB

    2. Cat Lover*

      What do you want to know about EOBs? It is your insurance giving you the breakdown of the charges.

      1. CatCat*

        I understand what it is. I want to help my family members who don’t get it grasp what it is. I am hoping there is a link that breaks it down very simply. I am not good at explaining it other than assuring them it’s not a bill.

        1. MsMaryMary*

          Unfortunately, every insurance carrier’s EOB is formatted differently. Some of their websites offer a tutorial, or your family member could call customer service and have them walk through the EOB with them.

    3. Insurance Q&A*

      Hi CatCat!

      EOBs can be confusing, for sure. They are truly not a bill – it’s your insurance company telling you that they got a claim from a doctor, and then breaking down what happened with that claim. They’ll tell you how much the doctor billed, how much the insurance company paid, anything the insurance company denied, and then – most importantly – how much the provider is allowed to bill you. You should get an EOB in advance of any bill from the provider, so you can compare them and make sure that the provider is billing you correctly. Hope this helps!

    4. Guacamole Bob*

      My insurance company has started including information about which of the amounts I owe have been paid and which haven’t, and offering a “pay now” link online, so EOBs look more like bills than they used to. I find that confusing and weird – how are you supposed to keep track of what you’ve paid directly to the provider and what you’ve paid through the insurance company? Especially given how fragmented billing can be. My spouse had a colonoscopy and we got 3 or 4 different bills for $20-40 for the clinic, the office visit beforehand, the doctor who performed the procedure, the anesthesiologist, etc. I can easily see going “oh, shoot, I must not have paid this one” and paying through the insurance company only to find out the systems just weren’t quite synced.

      1. Insurance Q&A*

        That is so weird. Is your insurance through your employer or a different source?

        Procedures like colonoscopies do often have multiple provider bills that come after them, so I can see this getting confusing EASILY.

          1. Insurance Q&A*

            Oof. All I can say is keep VERY clean books… (And give feedback to the insurance company that you are Not A Fan and that this is Confusing, etc)

        1. Lora*

          Not Bob, but I have United via work, and they do this. And the amount that shows up as “we didn’t cover this, you may owe” on the webpage version of the EOB has a button next to it saying “pay now” which lets you pay via the insurance portal. And you can pay it…or you can wait for the provider’s own billing to bill you, and often those don’t match up for the same procedure. Either the provider decided to write it off, or they discounted it, or some mysterious arcane thing happened in their AP/AR system…who knows. I have a huge dossier and Excel spreadsheet from a hospital visit last year, matching up all the payments vs bills to be sure I got them all correct. I know that they’re trying to be helpful by compiling things, but when nothing matches up exactly you have to keep track of it all offline anyway to figure out what you already paid and who owes you a refund because they billed you for something else, etc.

          1. Generic Name*

            Yep. I have United and have seen this “pay now” button. The first time I saw it I was like, wait, don’t I owe the provider and NOT the insurance company? No way am I clicking on that button. If the provider thinks I owe them money, they can send me a damn bill. Often I’ll see that button but I don’t get a bill, so I assume that the provider is satisfied with whatever insurance reimbursed them and haven’t sought to recoup the difference from me. Just about every EOB I get shows a difference between what the provider submitted to United and what United paid them, and I don’t think I’ve ever paid a provider more than whatever my copay is. It’s really weird and confusing.

            1. Guacamole Bob*

              I usually just ignore it all until I get a bill, but then I had one pretty standard doctors visit with some very normal blood work where I never got a bill until months and months later I got a collections notice. Fortunately my credit is fine and it didn’t really matter in the long run, but I was annoyed. So I try to kind of keep track of whether I’ve paid for things, especially from that provider.

              The timelines with insurance are annoying – you go see them on day 1, they bill insurance so you get an EOB on day 26, and get a bill from the provider on day 43, and that’s if everything is going smoothly. If you go to the doctor more than occasionally it quickly gets hard to keep track. Is this bill that looks similar to one I got a few weeks ago from a different appointment, or did I forget to pay the prior one, or did they receive my payment after they ran this batch of billing? Who knows?

              1. Insurance Q&A*

                Yep. The timeframes are utterly amazing. I spoke with someone who received their first bill over a year after their appointment because the claim was submitted to insurance, it processed, the doctor asked for an adjustment, that processed, etc, until a year had gone by. The caller was UPSET, and rightfully so.

            2. hodie-hi*

              So glad I’m not the only one who finds this (United) confusing and not good. I am a word person, not a number person, so this makes my head swim. I cannot keep track of all of this, and have lost track of what’s due to whom, whether it’s paid or over-paid. I’ve even gotten a refund because I’d double-paid something.
              One of my providers has an online payment portal that worked great and was easy to understand, but something changed and it no longer works. I’ve had to get the checkbook out for them. :-(

              1. Lora*

                If it makes you feel any better, I am very much a numbers person and when I see numbers not matching up my immediate assumption is that someone has their hand in the cookie jar. Unfortunately there’s not a lot of accountability to be had.

            3. Anon Supervisor*

              The “Pay Now” option is something that UHC is offering some contracted providers. The premise is that you pay UHC what they think you owe. Then, UHC sends the money they owe and the money you owe to the provider all in one pretty package. Basically, they’re acting as a middle-man between you and your provider. HOWEVER, I’m of the mind that I’m never going to pay for something based off an EOB and will wait for the provider to bill me.

              1. Mary*

                UHC is also taking a cut of your payment in return for being that middle man.

                As the person responsible for billing matters at my medical office: no thanks, UHC.

          2. Not So NewReader*

            Oh boy, you’re not kidding nothing matches. When my husband was in his final illness I kept a very detailed chart of his 67 appointments over 13 weeks. I had dates, time, where, who, you name it.
            I could not get the bills to match up with what actually happened. The dates on the bills were wrong. They changed the names of the doc/organization around to other names. It was beyond comprehension.
            And they would put a code number with no words. Since I could not sink any more time into sorting all this, I just paid everything that said, “balance due”. I cannot put into words what this did to me emotionally/physically and did to us financially.

      2. Ooh La La*

        Yep. I have Aetna and I can pay claims through the app. It’s very confusing – am I paying the insurance company? – so I ignore it and wait for the provider to bill me. But the option is there.

      3. Elizabeth Bennet*

        Guacamole Bob – Once upon a time Intuit had a medical expense/EOB software tracker for this exact purpose. I would LOVE if they brought it back, but I’m a beancounter kinda person. Excel has to do for now. Input EOBs with details, marked as paid with details.

    5. Snailing*

      CatCat, I’ve had luck with telling people that the EOB tells you what you can expect the provider to bill you. And I always advise them to keep the EOB and do nothing until they get the bill from the doctor (which can come WEEKS later!) – then compare the amount you owe and if it’s not the same on both, call your HR/your benefits manager/the insurance customer line for help.

  10. Anon4This*

    Do you have any advice for getting someone on the phone who can help with a more specific or specialized question? The question I most often have when I get on new insurance is “Can you tell me whether under this plan, insulin pump infusion sets and continuous glucose monitor sensors are covered under Durable Medical Equipment or Pharmacy, and can you direct me to the in-network provider for these supplies?” The biggest pain by far is finding someone who knows what I’m talking about or will at least help me find the answer.

    1. HMM*

      I’m not the person who penned the original advice, but as a benefits administrator, I’d recommend you go to your HR person or benefits administrator to ask for help. They usually won’t know to that level of detail, but should be able to ask their contact within the plan or insurance broker to help answer that for you. You may also be referred to calling the health insurance provider themselves, whose reps will specifically look up your plan and investigate to see whether what you’re asking about is covered. Larger insurance providers will likely have a hotline specifically for these kinds of questions for new enrollees. You can also ask your doctor’s office whether those things are commonly covered by the insurance or participant.

    2. Insurance Q&A*

      Oooh yes, this is a really common question. I like HMM’s advice to go to your benefits administrator.

      I’m sure you’ve tried calling in to the customer service number and that hasn’t been super helpful, but you can always try calling in and asking immediately for a supervisor. This isn’t my favorite tactic, but in your case it should give you a better chance of success.

      1. Insurance Q&A*

        For a lot of companies, Diabetes will also qualify for a case manager, so you can see if you can get in touch with the case management department for assistance figuring out coverage.

    3. Sanity Lost*

      THIS!!! My parents went through the wringer trying to get information on what is covered when they retired and went to to Medicare. My dad’s health issues are rather complex and he and his Dr have a very detailed health plan for him to deal with those issues that has worked for years with only minor tweaks. None of the Medicare folks they talked to could say whether if this or that med or particular equipment (CPAP machine for ex) was covered. Their suggestion was try it and see if it went through. Yeeeeahhh. My dad was a quality assurance auditor for 40 years, “try it and see if it passes” is NOT an acceptable answer to him.

      1. Insurance Q&A*

        That really shouldn’t be an acceptable answer to anyone, and I’m so sorry that he got that as an answer. I’m REALLY limited in my Medicare knowledge from the patient side, so I’m not able to give great advice in this case, but I would reach out and see if there’s a case management team that can help untangle things in cases like this.

    4. Business Socks*

      Hi-I’ve worked in the insurance industry for a while. Do you get your insurance individually or through an employer? One sad but true fact about health insurance is they can be a pain to deal with as one person, but an employer group (especially a big one) holds more sway. If you get your insurance through your employer and your company is big enough to have an HR department, it may be possible to bring your issue to them. Larger employers are generally assigned an Account Manager whose job performance is partly based on retaining their business. If an HR team brings an issue to the AM, issues and questions can be handled much quicker than with one person going through customer service.

      1. Insurance Q&A*

        YUP if you can get your employer on-side, the insurance company will be very responsive. They like to keep their employer groups happy.

        1. Kyrielle*

          Definitely! Years ago I got the “try it and see if it goes through” answer…I needed allergy shots and was looking at a $2400 bill for creating the initial bottles. I needed to know if my portion was going to be $240 (covered), $2400 (not covered), or something else (if I had the categories wrong). And they wanted me to have it done and billed to find out. It was in the category of things they wouldn’t guarantee was covered without a pre-auth, but they wouldn’t do a pre-auth.

          I reached out to our HR, who reached out to them, and I had an answer in days. (It was covered. And fortunately for my sanity, that answer was accurate.)

    5. COBOL Dinosaur*

      Another thing which might help is to get a procedure code from your doctor’s office. If you provide the specific procedure code you would like covered to the insurance rep on the phone it might be easier for her to look up the information.

      1. Insurance Q&A*

        Agreed. And honestly, I know this isn’t across the board insurance customer service practice, but I train my reps to reach out to the doctor’s office to get those codes if you don’t have them. If you don’t have the code, ask the rep you’re on the phone with to call your doctor and get the codes.

      2. Snailing*

        To piggyback, if it’s for pharmacy, each plan will have a specific “prescription formulary” that tells which prescriptions are covered and at which tier, which will tell you how much you’ll need to pay for them. This is all available through the insurance carrier or your HR and/or benefits manager should be able to get this easily!

        For DME, though, procedure code would be best for sure.

  11. Researcher*

    I. Learned. So. Much.

    My sincere thanks to the reader/author for this enlightening post!

  12. NotRealAnonForThis*

    When we had a major medical issue with one of my children, we were immediately given an insurance company case manager, by our insurance company. I have NEVER been so thankful in my life, as this wonderful woman helped us navigate every aspect of our child’s care for the next 3 months, starting with the fact that since it was an admission-able-event, suddenly every children’s hospital in my entire state was now considered in network, and every provider under those hospitals were also considered in network.

    She advocated for us on several initally denied treatments, even fielding a three way phone call with our infectious disease doctor who basically said “yeah, we know that there’s a cheaper drug. The patient went into anaphylaxis with three other drugs in that family of medications, so no, no we are NOT trying this one first.” Strangely enough that denial got reversed in a matter of seconds!

    If someone on your plan has either a chronic condition requiring treatment, or a major medical emergency, this might be something to inquire about. They know how to handle the red tape. They can explain EOB’s. They can even answer your “WTH?!?” when you get a survey asking if your child’s treatment was due to a fall or a car accident, which is apparently standard that they’ll look for another insurance to subrogate to if they can.

    1. Cat Lover*

      “They can even answer your “WTH?!?” when you get a survey asking if your child’s treatment was due to a fall or a car accident, which is apparently standard that they’ll look for another insurance to subrogate to if they can.:

      That’s pretty standard for any head/neck injuries as well. I have an MRI for my neck and got a letter in the mail to do an accident questionnaire. They want to make sure car insurance (or other party) should be paying.

      1. Insurance Q&A*

        Yeah, those surveys are really common with any diagnosis that might possibly sometimes be related to a car crash… They’re basically the insurance company looking for “do we have to pay, or can we pass this off to the car insurance company?” when very often the answer is “No, no car accident, please pay up…” Similar ones get sent out for diagnoses often related to property insurance, and worker’s comp.

        I’m so glad your case manager was awesome! It’s one of my favorite things to train on BECAUSE it can make such a huge difference.

        1. NotRealAnonForThis*

          We figured that there was probably some dollar threshold where they just asked “is there any other insurance company in play, or can we sue someone to recoup the treatment costs?” by sending these surveys. We got them after emergency joint surgery, for inpatient PT, for outpatient PT, outpatient home care, etc.

          She was absolutely AMAZING.

        2. Guacamole Bob*

          There can also be other insurance at play for some kinds of school and college sports.

        3. What's in a name?*

          Are these forms required to be returned? I feel like it’s just another hoop to jump through.

          1. ExtraInfo*

            Not the OP, but the fine print of your insurance agreement probably contains some kind of statement that you agree to assist them with coordination of benefits. Failing to provide them with information pertinent to that process could be interpreted as a violation of the contract and could allow them to legally pend or deny payment for the claim.

          2. Cat Lover*

            Yes. Usually you can do them online. The one I did for my MRI took less than a minute.

            They will probably deny claims if they don’t hear from you.

          3. NotRealAnonForThis*

            The phrasing on the form certainly made it seem as though it needed to be returned unless You Want To Be Stuck With Full Fare.

            It really seemed like a stupid hoop to me (being in a situation where they couldn’t go after a third party as infectious disease and the county health department couldn’t nail down where the source of infection was) but was either a check box and drop it in the mail in their provided postage paid envelope, or go online to handle it. We were somewhat lucky in that they DIDN’T show up while our child was inpatient, because it would have most likely fallen through the cracks had it done so; hospital sleep is never good, and being the in-room parent of a very ill child is exhausting on top of it.

      2. Liz*

        or anything! I was dogsitting for friends, when I caught my heel on the metal thingy that goes across the door jam, and badly twisted my ankle. After it didn’t get any better, I went to the urgent care. And I guess, based on what I said about HOW I did it, then got something from my insurance co., asking for info about my friend’s homeowner’s coverage! I guess to make sure there was no negligence.

        I called my ins. co and said nope, it was just me being clumsy, and not like i stepped in an open hole, or anything like that.

        1. Insurance Q&A*

          Greetings fellow klutz! I also have received surveys for similar graceful moments. I’m sure whoever sees my responses just knows at this point “Oh, she trips on air, got it, moving on.”

        2. ExtraInfo*

          Here’s the part that makes this sort of thing really tricky and awkward: even if there was no negligence on the part of your friend, there’s a possibility that, legally, her homeowner’s insurance would be primary for payment of injuries that occurred on her property. If your insurer has reason to believe that another insurer could be responsible, they may have the right to deny your claims until they’ve investigated what other coverage exists.

          1. Case of the Mondays*

            They are not supposed to deny your claims. They are supposed to issue conditional payment and then get reimbursed from the patient’s claim against the third party. If the patient won’t make a claim against the third party, they can in your stead.

            1. Insurance Q&A*

              Whether supposed to or not, the denials happen all the time.

              So does the second method, don’t get me wrong – paying the claim, then going to the correct party for payment.

              but I’ve seen it go both ways pretty evenly.

    2. Case of the Mondays*

      Interesting and good to hear! I have a couple of chronic medical conditions and I avoided the case manager like a hot potato. I thought they would try to meddle in my care and have me try cheaper things.

      1. Insurance Q&A*

        They’re really there to help you – and if they do start meddling, you can say “no, thank you!” and end services :)

  13. MsMaryMary*

    I work in employee benefits and unfortunately spend a lot of time with medical claims. Here’s my two cents:

    – See if your insurance carrier will contact your doctor BEFORE you appeal a denied pre-authorization, treatment, or medication. Most carriers have a “peer to peer” review process. Sometimes a denial is because your provider didn’t check one box or phrase things a certain way, and a conversation can clear that up the issue in a matter of minutes.

    – If you have to appeal, involve your doctor again. Getting a copy of their notes or having them write a letter on your behalf can be helpful. Generally, I have not found it effective to tug on heartstrings or include details on how a denial impacts you and your family. Unfortunately. The more medical facts, the better.

    – You get at least one internal appeal of a denied claim or procedure. Some plans offer two. And under ACA you get an external appeal (where the decision maker does not work for the insurance company) as well. It is time consuming and annoying, but I have seen denials overturned by the external appeal.

    – While you are appealing, ask that billing put your bills on administrative hold so you don’t go to collections. You may need to ask again every 30-60 days.

    – If you have employer sponsored coverage, get your HR or Benefits team involved. They have other routes to escalate your issue, and the good ones want to help you. It can also help identify systemic issues. Either if a lot of people want services that currently aren’t covered, or maybe an error in terms of how your plan was set up. If you don’t want to share all your medical details with your coworkers, ask if there is someone like me, a broker or consultant, you can go to directly.

    1. Insurance Q&A*

      YES all of this! I was trying really hard not to write a novel for Alison, but this is all ABSOLUTELY FANTASTIC advice.

  14. Mr. Cajun2core*

    It may be worth to look into your high deductible option even if you have a large number of expenses. My employer’s high deductible option has a lower out-of-pocket maximum than the regular plan. I always reach the out-of-pocket maximum for the high deductible option but I would never reach it for the traditional plan. Yes, the beginning of the year is expensive but the end of the year is free!

    1. Insurance Q&A*

      Yes. I have Strong Opinions about the proliferation of high deductible health plans to the exclusion of other types of plans, BUT if you have a large number of expenses they’re usually a good bet – your out of pocket maximum is often lower than a copay plan, and like you said – pay a lot in the start of the year, but then you’re free and clear, with lower premiums than the other policies.

      1. Hello Friends*

        My work just started offering a high deductible HSA plan this year. In the end, I would have saved about $9 per month is all compared to my, admittedly, extremely good HMO plan. And my employer “generously” would have contributed $150 towards my health savings account. One primary care visit and the cost savings/employer contribution would have been nearly wiped out. If the employer contribution was increased, especially considering that my employer would save about $900/year if I were on this plan, then I would consider it. But definitely not worth it at this time.

    2. ThatGirl*

      I’ve gone for high deductible plans for the last few years because the company contributes a certain amount to the HSA, so basically the first $500 or whatever is covered – and if I don’t use that money, it’s mine, and I can also use it for things like new contact lenses or glasses. But I am also young-ish, healthy, and don’t go to the dr. much. So that may change as time goes on.

      1. Insurance Q&A*

        Yes, high deductibles are great for people who have very low medical expenses and very high – not so much for the middle, unless the employer kicks a lot into the HSA.

        For HSA/FSA, I’m sure you already know this, but keep your receipts :)

        1. Mr. Cajun2core*

          Thanks for the info. I am lucky that our HSA is on a card. Do I really still need to keep receipts? To be honest, I have not been. What is the danger if I don’t?

          1. Cat Lover*

            They might request proof of payment. If you don’t have individual receipts, your provider can provide a statement which should have all of your payments on it (my office does this).

          2. NotTheBoss*

            Not Insurance Q&A but have been in the industry for 16+ years. You still want to keep your receipts even if you have a benny /debit card because sometimes you will have to show that the expense is qualified. For example, my vision hardware plan never covers the entire cost of new frames and lenses, so I use my benny card to cover the balance, and then I have to provide the detailed receipt so they can see that I wasn’t charging something that isn’t covered, like eye glass cleaner or non-prescription sunglasses.

            1. Mr. Cajun2core*

              Thanks for the info. I may start keeping receipts for large items but there is no way I can keep receipts for all of the prescriptions I have!

              One good thing is that my HSA card is good enough that it generally won’t let me charge things that aren’t covered. For example, for some strange reason, it won’t let me charge syringes even though I have a prescription for an injectable medication.

            2. Insurance Q&A*

              Yes, still keep your receipts for your HSA/benefit card for if you’re asked for proof of payment. Easier to pull out a receipt than repay the HSA…

        2. tamarack and fireweed*

          The US is the 4th country I have lived in as an adult, so by now I’m a little worn out from figuring out another health care system – and one that’s 10x more complicated to boot.

          My employer offers three plans. The high deductible plan has a $1250 deductible and a $5000 out of pocket maximum. The most expensive plan has a $750 ded. and a $ 4250 oop max. The least expensive plan is called “consumer-directed”, has the highest deductible, some different rules, caters to libertarians, and comes with a HSA that is not “use it or lose it’. I ruled out the third. But looking at the differences between the first two, if you don’t have to minimize the deductible (ie, if you have the capacity to save up ~$1000, which I do) the “high deductible” is the better deal as my payroll contribution to the lower-deductible plan is > $1300 / year more than the high-deductible plan! To help us decide, they provide three scenarios about how much you would pay out of pocket (having a baby, managing well-controlled diabetes and an uncomplicated leg fracture). In each case the difference I would have to pay out of pocket between the first two plans is $300-400. Not worth the higher payroll contribution! Especially since right now my health needs are moderate (worst is a possible elective orthopedic surgery in the future). But even if I have a catastrophic year the difference is $750 in oop max.

          (Dental and vision are identical between the plans, except that the 750 plan includes orthodontics. I presume if you have children on the plan that would make a different to some of my colleagues.)

          1. Elizabeth Bennet*

            Another advantage to an HSA is once you turn 65, you can use the funds in the account for anything, not just medical expenses. And, the HSA is yours forever, regardless of your employer. You can contribute your own funds to it (not payroll deductions) until you’re enrolled in Medicare, and the funds can be invested and grow tax-free. So, you could use it as a retirement account. Withdrawals are not taxed.

    3. A Genuine Scientician*


      I am on the high deductible plan from my employer because the monthly premium is so much lower that I am *guaranteed* to spend less out of pocket on the high deductible plan than any of the others. The high deductible plan has a lower yearly out of pocket maximum, lower monthly premiums, and my employer makes an HSA contribution for me for using it, so it ends up literally always being cheaper.

      1. Insurance Q&A*

        Nice. THIS is the way for an employer to do a high deductible ethically, honestly.

        1. Blackcat*

          I once had a high deductible plan where my employer self-insured for the entire deductible. I have no idea how that was cheaper, but it was. All I had to do was send my EOB to someone in HR, and the amount outlined in the EOB would be direct deposited to me within 48 hours. So I didn’t even have to get reimbursed.
          It worked great from my perspective.

        2. fhqwhgads*

          Can you tell me from your perspective what you consider a “high deductible”? I see that phrase a lot, and the range of deductibles I’ve seen offered on plans from past and current employers is anywhere (ignoring zero deductible plans atm) from $1000 to $5000. Where’s the line for “high”?

          1. Cat Lover*

            I’ve seen patient with $6,000+ deductible plans. Also, some have individual *and* family deductibles. Some people with many dependents on their plan may reach the family ded first, so it really depends on your situation.

            1. Insurance Q&A*

              Generally “high deductible” is anywhere from $4k-$6750 for an individual, and up to $13k for a family (plus an individual OOP max to keep one person from owing the full $13k), for the plans I’ve seen. It’s a specific type of plan defined by the ACA, so some deductible plans don’t fall under this umbrella because of how the deductible accumulates on family plans.

  15. GII*

    Is there a form I can fill out when preparing/preauthorizing for surgery that effectively says “Nobody out-of-network is allowed to be in my operating room in any capacity, I do not consent to it, and would rather you let me die than bankrupt me with surprise out-of-network personnel while I am unconscious.”? I wish I were joking, but I am not.

    1. Insurance Q&A*

      Oh I SO wish this were possible from the insurance side. It might be on the hospital side, but I’m not sure on that.

      If you do get stuck with an out of network anesthesiologist, radiologist, etc, check for Hidden Provider or Surprise Bill laws in your state that can be used to get those claims processed as in network.

      1. Distracted Librarian*

        My state has such a law–but they exempted themselves. It doesn’t apply to any insurance plan from a state government employer. I wish I were joking. I was able to get the bill reduced (though not to the in-network amount) by calling the provider and pleading my case.

        1. Snailing*

          Not sure if this will work everywhere, but in my smallish town, we have ONE group of anesthesiologists and only one major hospital nearby for surgery. The anesthesiologists group did not (until very recently) participate with one of the major insurance companies on our area. We’ve had luck with calling both the provider group and the insurance company and saying basically there is no other option for anesthesiology in our area, and it was obviously a necessary part of the surgery, so you must treat this as in network. It takes some fighting, but typically it has worked. So if there’s no in-work option, you may have luck with this approach if this should ever happen!

          1. NotRealAnonForThis*

            In my not small-ish town, with more than one anesthesia group and five (I think? Used to be) major hospital systems, I have YET to encounter one “In Network” anesthesia group other than a major pediatric emergency (when our case manager informed me that every pediatric hospital and every provider through said hospitals were considered in-network for our case). I don’t have some random insurance either, I have one of the biggest providers nation-wide.

            Massively frustrating. You can’t do surgery without anesthesia (find me a surgeon who will do it), but they’re claiming that its out of network while there are no in-network options?

    2. Miss Muffet*

      I think you can get that nailed down before the surgery with the hospital. My husband just asked the question during some of the pre-op stuff, and I think talked to someone at the insurance company too, just to make sure.

    3. MsMaryMary*

      No, but at the very end of 2020 Congress passed a law prohibiting “surprise” billing in situations where patients have no control over whether their providers are in or out of network. This includes ER personnel, anesthesiologists, lab techs, ambulances, and other providers who are frequently a problem. The law is not effective until 1/1/2022, but a lot of states have similar laws in place already. This is also an area where you can appeal if, say, your anesthesiologist happened to be out of network while you had surgery at an in network, facility with an in network surgeon.

      1. Ama*

        I had to invoke the no surprise bill law in my state (NY) a couple years ago when some blood work was sent to a lab that was out of network without my knowledge or consent. It took a while to resolve — I had to fill out a form with my insurance company confirming that I had not been informed my blood work might be sent to an out of network lab nor did I sign anything consenting to the use of out of network providers, and then the insurance company had to contact the provider and ask them to confirm they didn’t have any documentation that I had consented (which they didn’t), and then they finally processed it as an in network claim (which is what is required under our state law). It was a little frustrating while the endless correspondence was happening, but it did ultimately resolve in my favor.

        1. Insurance Q&A*

          Yep, they can take a bit, but if it can resolve the bill for you, the frustration is usually worth it.

        2. NotRealAnonForThis*

          It took two years to resolve an out-of-network charge incurred due to an out of network doctor responding to a code while I was in labor. As I was unconscious, its not as if I could ASK if he was in-network. I somehow doubt it was in my husband’s thoughts at that point either. Predated this type of legislation being on most radars.

        3. fhqwhgads*

          I had this happen too, but the amount they were charging me was less than $25 so I just paid it. It didn’t seem worth what I expected to be a ton of back and forth. It pissed me off on principle tho. It should’ve been covered and no cost to me.

      2. DataSci*

        That’s great news about the new law, do you have a link to any information or the official name of the law for Google purposes? “Out-of-network anesthesiologist bill” is one of my nightmares.

  16. Admissions*

    It sounds like you need to start an Ask a Health Insurance Expert blog. I would read it.

      1. Admissions*

        If you do, be sure to share the link so we can all start submitting our questions. :)

  17. Mr. Cajun2core*

    Does anyone else have any issues with getting your optometrist to send in the claim to both your medical *and* your vision insurance? I am diabetic. Because of that, my optometrist states that they have to submit the claim to the medical insurance. However, the medical insurance does not pay for refraction. I have to pay the $34 for the refraction out of pocket. They claim they can’t submit claims to both the medical and the vision. I am working with my employer to get it straightened out but I have a feeling I will have to fight my optometrist and/or just send it the bill for the refraction directly to the vision insurance company myself.

    1. Insurance Q&A*

      Yeah, this is a thing that happens a lot when multiple plans are involved… What usually happens is the provider will send the claim to one insurance but not the other, and leave it on you to send it to the second insurance policy. Sometimes this is because the second policy needs the denial on paper before they’ll pay out.

      If your employer can’t get it figured out for you, and I truly don’t mean this flippantly because I know how difficult finding a good doctor is, try looking for an optometrist who will actually submit to both insurance companies for you.

      1. Guacamole Bob*

        Having multiple plans is a huge pain in the neck. I had grad student coverage one year that ended at the end of January, but my spouse’s insurance started on January 1st. In most times that wouldn’t have been a big deal, but that month happened to be the birth of my twins, and tens of thousands of dollars in hospital expenses got billed to the old insurance when the new insurance was supposed to be primary, resulting in a lot of phone calls and paperwork while I was home with two infants.

        The most frustrating part is that the two plans were with the SAME COMPANY! I think the university was self-insured so it actually did impact who ultimately paid the bill, but still. At least the entire department at the insurance company that was devoted to such circumstances was reasonable to work with.

        1. Insurance Q&A*

          Yeah, this is where I really love to spend my time when I’m not actively training – looking at coordination of benefits situations to see if I can help untangle them, because they can be such a monster.

          1. Guacamole Bob*

            Thank you for that! The fact that the people in the coordination of benefits department were helpful really helped a lot. Once I learned the language around primary and secondary insurance and how to let providers know to resubmit to the other insurance, it went fairly smoothly, at least compared to many insurance horror stories.

            Fortunately my daughter was only ever on one plan so her week-long stay at a different hospital at two weeks old was all billed correctly the first time. Insurance nightmares often hit when people have the least bandwidth to deal with them – because when you have thousands of dollars in medical bills you’re probably dealing with a significant health issue! – so having someone helpful on the other end of the phone makes a big difference.

            1. Insurance Q&A*

              Yes, and in super complex cases, my company at least has a group of reps that work 1:1 with people instead of having a bunch of different hands in the pot. Always worth asking for, if you get stuck in one of those nightmare scenarios.

      2. Mr. Cajun2core*

        Glad to see it is not just me. Yes, especially since my optometrist just retired, I very well may be looking for a new optometrist in the near future. My optometrist was with a chain or franchise (I don’t know which).

        1. Insurance Q&A*

          Ahhh the chains…

          You’re very definitely not alone. When you’re looking (haha), you can ask how they will handle billing in your situation before you become a patient, so at least you know what’s coming.

          1. Mr. Cajun2core*

            “looking” LOL. Yes, I definitely plan on asking them how they would handle that before I become a patient.

        2. Heather*

          We changed dentists over a similar issue when my spouse worked for the feds. Federal BCBS medical has (had?) a small dental benefit that has to be billed and collected before the actual dental insurance would kick in. Our old dentist’s office would. not. bill. correctly. Nor could they provide me with properly coded bulls so I could submit correctly. I literally spent over 15 hours on spouse’s filling claim. We switched dentists after that and it’s been the first thing I ask each time we’ve moved and have to find a new dentist.

        3. Blackcat*

          I am fiercely loyal to my optometry/ophthalmology. The optometrists are meh, but my retinal specialist is great and their billing team is FANTASTIC.

  18. RegBarclay*

    This was really helpful, thanks!

    Do the “prudent layperson” laws cover bystanders calling? I have epilepsy and fear that if I have a seizure in public, someone will call an ambulance that won’t be covered since 1) seizures aren’t life threatening in and of themselves and 2) I won’t be conscious enough to refuse.

    1. Insurance Q&A*

      They should, yes. As long as you can show that a “normal” person could have a reasonable belief that a medical emergency was happening, you should be ok. I say should, because, as much as I wish I could guarantee this working… It’s not entirely foolproof.

      I’m so sorry this is something you have to worry about.

      1. PT*

        I am glad you answered this question, this is something that wore on us at work a lot. I was safety captain in a fitness center , and our policy was to call EMS for things like fainting, seizures, chest pain, dizziness, severe shortness of breath, and doubly so if any of those symptoms was the result of an in-water rescue in the pool area.

        But obviously, we encountered a lot of people with chronic health conditions are trained to provide self-care for such symptoms. We also encountered a lot of people who were in denial that they were ill and would insist they were fine even when they were clearly very not fine. For the borderline cases it wore on us a lot. Do we err on the side of caution and call 911, and risk the person getting a huge bill for something they could have handled on their own? Or do we listen to someone who is embarrassed to be having a medical emergency in public and just wants us to go away and risk missing out on getting them care in a critical time window?

        It sounds silly but it was very stressful.

        1. Insurance Q&A*

          I can only imagine the stress. I would personally err on the side of caution, unless it was clearly a condition they were able to self manage. They may still get a bill, but prompt care is usually cheaper than delayed care – and they’ll be alive to complain about it.

    2. London Falling*

      Wait, what? You have to pay for the AMBULANCE? How does that even work? I don’t understand. I knew that you have health insurance in the US but I guess I always assumed that ambulance services weren’t part of that, because…. well, because it doesn’t make any sense!

      What happens if you’re unconscious and someone calls the wrong… ambulance company? Are those a thing in the US? Is the bystander who sees you collapse supposed to check your wallet to see which ambulance to call? How do you even know whether to call an ambulance fir someone?

      I’m sorry, I’m just so confused by this. I thought I mostly understood how insurance in the US works for healthcare, but apparently not?!

      1. Beth*

        Ambulance companies are absolutely a thing here! But you don’t call them directly, generally–people just call 911, and whatever gets sent, gets sent. In theory, if you call an ambulance for someone because as a bystander you have legitimate reason to think there’s a medical emergency, their insurance should cover it. In practice…well, you don’t know if they have insurance at all, and even if they do, not all insurance providers will actually play nice with this in all circumstances. It sucks because I basically feel like I can’t call for medical services for someone unless they’re clearly in a life-threatening crisis; if someone is even semi-conscious, I’m more likely to ask them if they want me to call them an uber to the hospital.

        1. Savannah*

          Yep an uber/lyft is infinitely less risky money wise and can also take you to an in network hospital, which an ambulance might not! medical risk a different story.

      2. Always a nurse*

        In most of the heavily populated areas of the US, there are fire department rescue/ambulance services. But in more rural areas, or just less populated areas, there are private ambulance services, generally only 1 per area, since it’s not economically feasible to have multiple services. Those private services respond when the first responders (fire or police) call for an ambulance to transport someone. They may call when the person needs to be seen in the ED, but it isn’t an actual life threatening injury. The private services also do intrafacility transfers, for example if Hospital A stabilized an accident victim, but doesn’t have the specialty services needed for continued care, they will call the private service to transport the patient to Hospital B, instead of tying up the true “emergency” responders. Calling 911 will get the true emergency responders, but transport might be from someone else. Those private companies can and do bill insurance companies.

        1. doreen*

          It’s not just private ambulance companies in rural areas – I just got an EOB for the claim my insurance paid for a city fire department ambulance. I’m sure the city doesn’t try too hard to collect from people who don’t have insurance – but public hospitals bill insurance companies and I’m sure most if not all public and volunteer ambulance services do as well.

      3. Ana Gram*

        I volunteer for a county EMS service that’s a mix of paid and volunteer providers. We bill but we do “soft billing” which means we’ll send you three bills and then never bother you again. If you don’t pay, we don’t care. If you do pay, great! And, yes, I tell my patients this.

      4. RussianInTexas*

        No, you call 911 for the ambulance, and they take you to the ER, if needed. Afterwards you deal with your insurance company, because there are charges and copays for it.
        Calling an ambulance is a very expensive thing, which is why such laws as “prudent layperson” are needed.

      5. Distracted Librarian*

        Wait till you hear about air ambulances. Someone gets evacuated via helicopter (or transferred to a hospital with a higher level of care via helicopter), then gets a $45,000 bill, which insurance does not cover.

        1. Insurance Q&A*

          Or fight for ages to have it considered medically necessary, and even then they don’t always win.

      6. Cat Lover*

        No, 911 is called. From there, 911 dispatches EMS out based on which due the address is in. Same for any 911 call.

        (I’m a volunteer EMT and drive ambulances).

  19. AnonEmployee*

    My prep for a colonoscopy was just denied because there are other less expensive ones available, the one my Dr selected is the one she prefers. I have to say though, this one I did not push back on because the prep she chose is GROSS, and the one I was able to get OTC is 1) Perfectly fine, as I have no issues that would preclude it from working on my effectively, and 2) Is tasteless! The out of pocket, had the Dr insisted, would have been $100, um, nope!

    1. Liz*

      I hear you. BTDT. Stuff like that, esp. when the cost isn’t all that much more, makes me scratch my head, because its a screening. Yes, it may cost more up front, but at least to me, it makes more sense to pay that, get screened, then have someone avoid it altogether, and suffer the consequences, i.e. cancer, adn then have WAY more medical bills for treatment of it.

    2. Insurance Q&A*

      ugh, yeah in cases like this the denial can actually work out in your favor.

      Side note: Preventive/routine colonoscopies can turn diagnostic during the procedure, so if your insurance company isn’t including the diagnostic benefits when you call, they realllly should be. I love that preventive are largely covered in full (thanks ACA!) but that possibility to switch while you’re still unconscious just irritates me.

    3. Bye Academia*

      Ugh, this is so frustrating. I had to get a colonoscopy last year due to some problematic symptoms. My insurance covered the procedure itself due to the symptoms, but doesn’t cover ANY prescribed prep for anyone under 50. I mean, I’m glad they covered the expensive part, but makes no sense that there is no exception to the screening age limit for the prep. The OTC prep just makes me throw up (I had used it twice for other, smaller procedures), so I found a coupon and ended up paying like $35 out of pocket for the prescribed prep.

      1. Case of the Mondays*

        Just FYI – you can get Zofran to take w/ the over the counter prep. That’s what I do to avoid the nausea.

    4. BeenThere*

      AnonEmployee, please share the name of the tasteless prep, please! I would happily pay double if there was no taste and even donate the same again to a charity of choice. That being said the price of preps seems so unreasonable to me, why aren’t they a $10/20 copay?!

  20. Health Insurance Nerd*

    This is such great information! As a fellow insurance person, I want to add- If you get a bill from your provider that you weren’t expecting, or that is for more than you anticipated, please call your insurance company before you pay it. It could be that you’re getting a balance bill (the difference between what insurance paid and the provider billed), or the claim was denied by the insurance company because the provider didn’t file the claim correctly, or within the terms of their contract or the health insurance’s guidelines/rules (in which case it’s the providers responsibility to fix it), or a whole host of other reasons that could lead to you not being responsible for the amount due. The insurance company should be able to advise you on what the bill is for, and whether you are truly on the hook for paying it.

    At my company we’ve had so many instances of members paying bills they should not have paid, we sort it out, and then it’s a battle to get the provider’s office to refund the member for something they never should have billed them for in the first place!

    1. Insurance Q&A*

      YES. I absolutely LOATHE when providers bill in error, and I ADORED calling them and telling them No. For real, if you’re not sure if a bill is legit, take the time to call. It’s worth it.

    2. MsMaryMary*

      Yes! Always wait for an EOB before you pay a bill, and definitely call your insurance if it’s more than you were expecting. Some providers get really excited about billing and send one out before they’re run it through insurance. Maybe it’s an innocent mistake. Maybe not. Also, if you’re asked to pre-pay or put a deposit down on a procedure or service, pay as little as possible up front. I have also caught facilities where the “deposit” turned out to be more than what the patient owed after the claim went through insurance.

      1. Savannah*

        Wish this was the case for all situations. Global billing for pregnancy + L&D feels straight up illegal with regard to how different it is than how the rest of insured medial billing works.

      2. Insurance Q&A*

        Yeah, facilities that want you to pre-pay your entire deductible amount before you go in and then drag their feet refunding you the balance… Or try to apply it as a “credit” to your account “for future services”… It grinds my gears until they’re just washers.

      3. Not So NewReader*

        Adding one more layer, the oncologist would not accept credit cards. Fun times.

        1. MsMaryMary*

          Did they want you to bring a giant bag full of money with a big $ on it? That’s borderline unethical to me, especially for a oncologist.

    3. Potato*

      Yes!!! Cannot second this advice enough. I was diagnosed with an auto immune disease in college, and in my early days I’d figuring out the intricacies of health insurance, had a claim denied even though I’d gotten prior authorization for the service. The bill got sent to collections and I was SO CONFUSED and very freaked out because ~broke college kid~.

      I was finally able to talk to an insurance rep who very kindly informed me that the claim was denied because the provider didn’t have an active license, and that the insurance company wouldn’t be paying the bill and I absolutely shouldn’t either. She very happily sent a strongly worded warning to the provider, and that was the last I ever heard of it. Couldn’t thank her enough!

    4. Sunny*

      I just spent a few months detangling this sort of mess after a surgery in December! Apparently the surgeon’s office messed up running my insurance and mistakenly charged me about $1200 in October (it was considered elective surgery, payment required before service), and then the facility where the surgery happened billed us another $1200 for the same thing in March. And then the surgeon’s office started denying that I’d paid them at all unless I attached the receipt I’d gotten to every email I sent. I finally got it sorted out and got them to process the refund last week.

  21. Chickaletta*

    I worked in ambulance billing for awhile. Some tips:
    – If you need more time to pay off, just ask. Be polite. People will actually make things work for you because honestly, there’s a large freakin’ amount of ambulance bills that don’t get paid and we’ll take what we can get. Our real beef is with the insurance companies who take too long to pay, some will make us wait years, and in the meantime, we can’t bill the patient or do anything else because we’ew just at their mercy. Dealing with a kind individual asking for a favor is a walk in the park compared to insurance companies and customers who yell at you. Being the latter will not benefit you, you’ll just get passed around.
    – Don’t write messages on your bill! Bills are processed by machines, so scribbling messages on the bill like “can’t pay” or “person deceased” or “what is this for?” won’t get read by anyone. You’ll need to call the customer service number. This should be obvious but you wouldn’t believe how many people send notes on their bill.
    – If you do send a letter to the company billing you, please be polite. The person on the other end is a human being who had nothing to do with your case until they read your note, and it’s not like they get paid more for helping jerks. They likely have some leeway in what they can do for you within policy, I’m just sayin’.

    1. Insurance Q&A*

      Yes seconding all of this. PLEASE be polite! And PLEASE don’t write on your bills! (Providers, PLEASE don’t handwrite notes on a mostly-typed claim for the same reason…)

  22. ThatGirl*

    This is timely! I’m not sure if there’s anything to be done about this, and ultimately we’ll manage, but.

    My husband has his own health insurance through his job, but had been on my work’s dental and vision plans because it was slightly cheaper. Back in November, I got laid off, and we weren’t sure how long it would take for me to get a new job, so he decided to enroll in his job’s coverage. He filled everything out, got confirmation on the website, etc.

    Cut to this week when he went to schedule a dentist appointment and realized he’d never gotten enrolled. He went back through his email and discovered an email from Dec. 18 – the Friday before Christmas and a time during which he is off for a month and not allowed to work – that said he needed to respond in writing before the end of the year to confirm his coverage. So his HR never enrolled him and he wouldn’t have seen the email until mid-January anyway. At this point he’s just going to find his own coverage for the rest of the year but we’re thoroughly annoyed and disgusted by how they handled it.

    1. Insurance Q&A*

      Oh for crying… He needs to reach out to his HR to get this corrected. When it’s an employer error like this they REALLY need to fix it, including backdating coverage to the start of the year. I am so sorry you’re dealing with this!

      1. ThatGirl*

        Yeah, his fear is that he will be blamed for missing the email, even though it’s ridiculous to assume anyone is checking their email at that point in the year, because the single HR guy is truly terrible. (I could tell a lot of stories that aren’t relevant here.) But thanks for confirming that it’s really dumb. :)

        1. Insurance Q&A*

          :( Obviously you know the situation better than I do, but if his HR guy tries to pull that, is it possible to go above HR guy’s head?

          1. ThatGirl*

            It is, but it’s hard to say if it’s worth it to my husband, for various reasons. (I am much more confrontational than he is and yes he 100% needs a new job, that’s a whole other can of worms.)

            1. Not So NewReader*

              I had a workplace where the bosses would argue with HR about insurance, especially if the employee was a good one. Some bosses are really in tune to how employees rely on their insurance and are most willing to advocate or escalate on behalf of their employee.

  23. IvyV*

    Something I became aware of this last year going through cancer treatment is that my state has a law making it illegal to surprise me with an out of network bill. So if I get surgery at my in-network hospital, everything is billed at in-network rates even if random person who treated me while I was sleeping isn’t. It also include emergency room visits that might be out of network. This law was only passed in 2018. This is very useful to know and so I provide the link below which has a list of the laws around this in each state:

  24. JB*

    Can you provide any insight into referrals? I primarily go to a medical complex with all sorts of different offices/practitioners. My primary care physician is there as well as every type of specialty, imaging, etc.

    I cannot get a consistent answer from insurance rep or from clinic staff as to when a referral is needed. Some very experienced staff have told me specific times (like podiatry) when one was NOT needed because “we’re all under the same zip code / aka provider number”. Podiatry department said “call insurance”. Insurance company demanded I see my primary care first to get referral. Turns out I did NOT need referral. So frustrating.

    1. Insurance Q&A*

      Referrals are weird. There are two different types – provider to provider, and then insurance. Most policies now don’t require the second type, where your PCP has to send in a request to the insurance company so that you can see a specialist. The first type are still a thing, where specialists require you to be sent over to them by a PCP or other doctor for treatment. These are to make sure that you’re going to the right person, so that, say, you don’t wind up at a neurologist when you actually need an orthopedist, or something like that. Most do still allow self-referrals, but they might have a more rigorous screening for self-referrals than for patients being sent over by another doctor.

      I’m sorry you had to deal with that frustration :(

    2. Case of the Mondays*

      Ohhh I might be able to help with this one. Podiatry is different from regular medical just like dental and vision and chiropractic are different. I had no idea until I had a podiatric procedure denied. I have excellent insurance too. It just doesn’t cover podiatry. I could see orthopedic or even a surgeon and have it covered. So, it makes sense that a podiatrist wanted you to double check your insurance coverage by getting a referral.

      I HATE the provider to provider referral recommendations. I have had a GI for 20 years. I shouldn’t have to call my primary to go to a new one. Also, if someone wants to bypass their primary to get a second opinion by a specialist, they should be allowed to do so and not blocked by the system.

      1. JB*

        Thanks. I was referring only to insurance coverage. And in this case, it doesn’t matter they type of medicine (that’s what I thought initially), it’s how this “clinic” (huge medical complex) is set up as a business unit. The safest course is to always get a referral. But I’ve been through twice, where that wasn’t actually necessary so cost me an extra primary care visit. But even knowing this, I can’t get consistent answer from either side. And one doesn’t want to be in a situation where something isn’t covered due to a technicality.

        Thanks for all the great info!

        1. LimeRoos*

          This might help a little bit – a lot of visits won’t need referrals if they’re being billed under the same TIN (Tax ID) or NPI – national provider number. So for your huge medical complex, you can ask the different departments what they bill under and if it’s the same TIN/NPI, you’re probably fine. Some providers have a few different TIN’s they operate under – like hospital vs. clinic, other practices they’ve absorbed, etc. It’s not a sure guarantee, but most providers don’t want to have to refer their patients back to themselves.

  25. Savannah*

    Such a great idea. I’m having a baby in august and will add her to my solo plan sometime in the 30 days after she is born. As I’ve already hit both my deductible and oop max for the year I’ve asked both my health insurance and HR if adding her to my plan will increase my deductible and oop max for L& D charges or her baby care charges during our hospital stay or if it will just affect her pediatric care after we are discharged. Insurance says to ask HR and HR says to ask insurance. Any insight?

    1. Insurance Q&A*

      It’ll probably go up as of her birthday. So you’ll add her within the 30 days, and her effective date on your policy will be her birthday. Since you’ve met your OOP max for the year, you’re unlikely to see more charges for yourself, but you’ll get billed for her services until her max is met.

      If you get a bill for her that says it was denied for no coverage, call the insurance company – the provider may have sent the claim over before she got added to the policy, but now that she’s on there the claim can be reprocessed.

      Congratulations! I wish you a boring pregnancy and easy delivery.

    2. Lady Kelvin*

      For what it is worth, here is how it worked with my insurance. All delivery/hospital related charges from when I was admitted in labor to when we were discharged 3 days later for both me and baby were considered charges against me and not the baby, that included circumcision, shots, etc, for baby. Once we were discharged, everything related to baby was under baby and everything related to me was under me. Our first doctor’s appointment for baby was 2 days post discharge (standard for our hospital to make sure everyone is thriving) and all those charges were covered under baby’s policy once we added him to our plan, even though technically he wasn’t covered yet.

    3. Snailing*

      Ask either your insurance carrier or you HR for your Summary of Benefits and Coverage – they HAVE to provide you this. When you look up the deductible and max OOP, there should be an individual amount and a family amount. If you are currently “employee only” you’re in the individual bucket, but once you add any dependent, you’re looking at the family numbers. (With most plans I see, it’s double the indiv.). Even better is if these deductibles and OOPs are “embedded” which means each individual is capped at the individual amount. So like OP said, you won’t owe anything else for your claims, just your child once added.

      Also, I’ve run into this frequently this past year because the social security office is behind – you should be able to add your child before the SSN is issued and then add it in later. Don’t let lack of an SSN prevent you from adding your child in the 30 day window or you cannot add her until your open enrollment!

  26. HereKittyKitty*

    Maybe this is too specific, but is it possible to talk your insurance company into covering a certain medication? I’ll be specific with my example: most insurance companies will cover Adderall, but not Adderall XR. The whole point of ADHD is that you sometimes have a difficult time remembering things, so I prefer Adderall XR because I only have to remember to take 1 pill, I don’t feel the bumps and it works well for me. Unfortunately, it’s not covered so I have to pay out of pocket for it. My insurance would cover plain old Adderall, but then I would have to remember to take 2-3 pills a day, evenly spaced, which feels next to impossible for me. Have you seen success with people requesting their insurer to cover a certain medication over another?

    1. NeonDreams*

      I’ve taken many calls along this line as a health insurance call center agent. What I usually tell people is to have their doctor submit an authorization to the insurance company explaining why a patient needs the the non covered drug versus the formulary (covered) option.

    2. Sharkie*

      I have adhd and I was in your boat. Call them and say “I’m on this medication for X reason. My doctor thinks it’s medically necessary” and they should be able to appeal

    3. AndersonDarling*

      Ugh! I dread changing insurance plans because of my husband’s Concerta. One of my plans had it priced as a tier 3 drug, along with chemo drugs!
      I actually posted a question above about appeals because the last time I had to go through it I tried to appeal and I was told for weeks that my faxes were not received. Then the appeal was denied. And at that point I was exhausted from running to Kinkos every week to resend the appeal forms that we changed my husband over to his own employer’s plan. We had gone months without his ADD meds so we had to make a tough decision. Overall it was a terrible plan, but his Concerta was covered and it was only a $25 co-pay.
      I’ve heard that insurance companies just ware you out so you give up. I don’t want to be so pessimistic, but it really felt like I was supposed to give up.

      1. Insurance Q&A*

        I’m so sorry you experienced that :(

        Some companies probably do just hope you’ll get too tired to keep fighting. It’s abhorrent that it’s even a consideration…

    4. AutolycusinExile*

      I had exactly the same problem with my XR, so I complained to my prescribing doctor in my next appointment and he/his office called the insurance company to tell them explicitly that it was medically necessary. (He is friendly to me, I know that isn’t universal, but assuming they aren’t bigoted enough to actually work against your interests even a meh doctor should be able to do this for you.) He told me this happens a lot, which is infuriating, but at least it means your doctor’s billing department probably knows how to get it done? Ugh, I hate that this is a thing, but here we are.

      Failing that, though, I guess I’ll take a moment to recommend GoodRx. Even once we finally got insurance to cover my meds it was still pretty expensive (for me, at least) and using a GoodRx coupon for my generic adderall without billing insurance took the bill from well over $100 to between $25-30. Still not free, ofc, but a huge improvement. I’m sure there are some regions where it’s harder to find a participating pharmacy, but it’s worth checking out if your insurance company won’t get its act together.

      1. HereKittyKitty*

        Yes, I do currently use GoodRX and it has been very helpful in making my pills $25-30 instead of 100s! I think I’ll try calling my insurance company first and if they don’t budge, I’ll have my doctor’s office try. They’re a very small office with only 2 receptionists and 3 doctors so I’ll do my due diligence first to make it easy- they really are wonderful though, so I have high hopes!

  27. Tex*

    I recently got a job with HSA, which is great! And I linked my insurance to it. However I had to have surgery and the ongoing billing process is a nightmare. The hospital, insurance company and HSA all show different amounts that they say I owe. (The medical event was not a one time deal, but a rolling basis). What is the best way to pay these bills that don’t affect my credit score? HSA portal payments seem to bounce back with regularity and take months to delay. I also receive random bills by mail or email from provider companies. I’ve spent way more time on billing than I was in surgery.

    1. Insurance Q&A*

      Ooof I’m so sorry you have to deal with this!

      Here’s what I would do. It’s a lot of work, but hopefully will get it all wrapped up.

      Step one: Call your insurance company and get a full list of the claims related to this surgery, including the doctor/hospital’s name, the total charges, what insurance paid, and what you’re liable for, for each claim.

      Step 2: Call your HSA and go through that list with them to see what matches and what doesn’t. Note dates of payment from your HSA, how the payment was sent, and who it was sent to, for any claims or amounts that were paid. Also see if they can find out why payments are bouncing.

      Step 3: With that information in hand, call your insurance company back and give them that information, then ask them to call the hospital billing office with you. When you talk to the hospital billers, go through the insurance company claim list again, make sure it lines up with the hospital billing office, and then go through and confirm the HSA payments that you have. After you do that, you should have the remaining balance that you owe. Keep insurance on the line for this entire call – this is part of their job, and they will be very helpful if there is a mismatch between the insurance records and the hospital records.

      Once you have that final balance that you, insurance, and the hospital agree that you owe, is there a way to pay it and then get reimbursed by your HSA instead of paying directly from your HSA? That honestly might be the easiest way to go, if the payments from the HSA keep getting rejected.

    2. MsMaryMary*

      The explanation of benefits (EOB) from your insurance company should have the actual amount you owe on it. If this doesn’t match what you’re seeing on bills, call your provider. Like I said in another post, some providers bill before running the claim through insurance.

      Does your HSA have a debit card associated with it? That should work like any other credit/debit card to pay medical bills. You could also pay the bills and reimburse yourself from your HSA funds. Some HSA administrators charge if you want to send yourself a check, but an electronic transfer should be no cost to you.

  28. NeonDreams*

    As someone who works for an health insurance company call center, this post is super awesome and validating. Part of me wishes I had written it because I love to write on the side. That being said, well done in explaining the complications that is the health care system.

    This might be an obvious note but insurance call center reps are people, too. We are trying our best to give customers the most accurate info possible. Sometimes we have to tell people something that negatively impacts their life (ex: telling people that a 4000 bill applied to their deductible, a certain medication isn’t covered,) We hate it just as much as you go. The call will go much smoother if customers don’t take it out on us. A lot of them do, and I get why. It’s stressful and maddening at times. Still, if each party respects the other, things will go as smoothly as they can.

    1. Insurance Q&A*

      Thank you! You’ve got a wicked hard job. Kudos to you for doing it.

      I 100% agree on remembering that call center reps are people, and often don’t have much control over the outcome of a situation. Treating them as compassionate people who also care about your situation makes things so much easier on everyone.

      Yes, it’s a super stressful situation, but yelling only makes it worse. As a trainer, once my classes get to the phones, my instinct every time a grumpy caller comes on is to just jump in and say “You cannot talk to my people like that. You now have to deal with me.”

    2. Not So NewReader*

      It can feel like the consumer is being told that no one is responsible though. How does the consumer find out who exactly IS responsible for the encumbrances/hurdles/obscurities?

      1. Insurance Q&A*

        Agreed, that feeling is really common.

        The way the system is currently built, sometimes there’s no perfect answer to “who’s responsible.” The system wasn’t really built to be confusing, but it is confusing because of how it was built – lots of hands, haphazardly, reactively.

        Often it comes down to a miscommunication between the provider (doctor, hospital, etc) and the insurance company. It shouldn’t be down to the consumer to do all the legwork, and you can absolutely insist that the insurance company work it out with the provider. If you’re not getting anywhere on your own, enlisting your benefits administrator or a patient advocate can really help get the problem clarified and resolved. I reallly wish I had a better answer :(

      2. AutolycusinExile*

        I think the most effective way to channel that (extremely justified!) anger is by pointing it at the people who design the system, instead. Find out who the company stakeholders are and TP their houses! /j

        No, but actually, if you can call your state representatives I think that has the best balance between power (more influence over policy than city/ county gov) and likelihood they’ll listen (fewer constituents trying to get their attention). I’d still stay away from yelling at the phone operator, of course, but at least then your ire will be directed towards someone in a position to effect change and you’ll go away feeling slightly less like you’re just ranting hopelessly into the void. Resistbot is helpful for this, especially if you’d rather email/text it too.

        1. Insurance Q&A*

          Yep, contacting your state and federal representatives is the best way to register discontent with this system.

          But be nice to their phone people, too, please.

  29. chellieroo*

    I have had good luck using my insurer’s online system (caveat: in a state with pretty good laws and with excellent coverage, compared to others in the US) to deal with coverage and billing issues (query: why are 100% of “billing errors” made in the provider’s favor? Statistics do not support this as being random. “Just end her a bill and maybe she’ll pay it” is more like it.) . The system was a pain to sign up for and isn’t very intuitive, but you have access to all of the dates, the procedure codes, etc. Using some of the strategies described in the article and the formal language embedded in the system (is this a “grievance”?) I have been reasonably successful at getting issues resolved. In writing. What a terrible nightmare for anyone who is not able to access technology or who is not very fluent in American Middle Class English.

    1. Insurance Q&A*

      Yeah, it definitely can be a nightmare. I am a huge proponent of using your insurance company’s website to the fullest extent possible, but like you said, it requires a level of fluency in American Middle Class English that a lot of people don’t have.

      Side note, I initially read that as “not very fluent in Middle English” and was still ready to wholeheartedly agree. It’s not written in colloquial English 90% of the time.

  30. Littorally*

    One thing I deeply appreciated my insurance doing for me — this was dental rather than health, but it was all through the same provider. Several years ago, I had a tooth break severely in the middle of a work day. I didn’t have a current dentist at that time, and was in too much pain to be really clearheaded. I called my dental insurance at a coworker’s suggestion, and they were able to locate a nearby dentist that was covered by our plan and could take me immediately. The insurance rep told me — “You just leave work and get over there, I’ll take care of giving them all your information and policy details.”

    It was a shitty situation, but the service really came through for me, and I appreciated it a lot.

    1. Insurance Q&A*

      oooo I am so sorry you had to experience that pain :(

      I’m so glad your insurance really stepped up! I handle dental, too, and I am so happy to hear that your rep made your awful situation a little easier to manage.

  31. NewYork*

    I have not read all the comments, but most very large companies actually self-insurance and just use the insurance company to service it. The employer is on the hook (although they may have insurance for large amounts). PRO: An HR person can likely help you. CON: Company may not want you around if you cost a lot (and they are smart enough as to getting rid of you for other reason)

    1. Hillary*

      The self-insured companies I’ve worked at have been very careful about firewalling this info. At my current org the insurance company keeps all individual usage info private, they essentially just tell the org what to pay. I know my leadership chain and my hr reps don’t have any knowledge of my claims.

      Usually if a company is large enough to self-insure they carry excess liability coverage on top of self-insurance. On the scale of a large company that insurance is cheap and even a horrible medical year isn’t *that* expensive. I think a big part of the reason for it is that it can be combined with workers comp management.

      1. Insurance Q&A*

        Yes, self-insured are really careful about maintaining Minimum Necessary – that nice provision of HIPAA that means that a person only gets the smallest amount of information possible to answer the question they’re asking. They do it partly because the people who handle the insurance part in the company are bound by HIPAA, but also because it’s better for employee morale and trust to keep it truly private. p

    2. MsMaryMary*

      It is illegal for an employer to terminate or take adverse action towards an employee because of health insurance claims. A lot of people are confused about what does and does not fall under HIPAA, but that scenario does. There are fines and possible jail time for flagrant disregard of HIPAA privacy protections.

      I agree that most employers are very careful about keeping medical claims data private, and often, they honestly do not know how who the claims belong to.

      1. NewYork*

        They know how much money is being spent, by employee. Not medical condition. And many companies smart enough to figure out an excuse to terminate people.

  32. lost academic*

    That’s the biggest thing I learned from my dad, a doctor: get on a payment plan asap! I went without insurance for a bit and needed an emergency outpatient surgery. I didn’t have any idea what to do and he told me to offer literally any payment amount I thought I could make every month and they would take it – even $5. Otherwise many offices are going to send your late bill after 30 days to a collector to make something off you and that’ll really screw everything up. They’d much rather have you be on a current plan than that – it means they’ll eventually get all their money. I had a bill of about $500 which was massive to me at 22, but I offered $25 a month. I paid it off and everything was great.

    1. Cat Lover*

      Yes!!! I work at a physical therapy office which can get expensive when coming 2-3x a week and our billing department is happy to set up payment plans if you cannot pay as you go or have an emergency (lose your job, etc).

      Also, ask if your provider provides a discount if you pay in full. My company gives 10% off.

    2. Insurance Q&A*

      Yes, payment plans are a GREAT thing. Providers, overall, are really willing to work with you because of exactly what you said – slow payment is better than no payment.

  33. whatchamacallit*

    Definitely look into setting up payment plans for large bills. I had foot surgery that pretty much was my entire out of pocket max, around $4000. I set up a 6 month plan with the hospital, and there was no interest or extra charges to do that. More importantly, when they stopped sending statements I called numerous times to ask what was up and when I finally got in touch with a person they couldn’t find my account, and if they can’t find it, I’ll have ended up not having to pay the whole thing.

    1. Insurance Q&A*

      Yes, payment plans can save you. I’m really curious that they lost your account, though – but I’m a fan of you not having to pay the whole thing!

  34. Being Sick Sucks*

    I’m on a medication that I absolutely need to take. Other medications that I’ve tried in the past didn’t work (it took almost a decade to get into long-term remission), and if I stopped taking this medication, even if only temporarily, I might not be able to go back on it. So having it covered by insurance is important to me.

    Every time I get a new job, I talk to the insurance company my employer offers, and they can never tell me if my medication would be covered. Sometimes the excuse is that different employer plans cover different medications, and the employer doesn’t have a test account, so they can’t check. Or they say I would need to apply for approval and see if the insurance company thinks it’s medically necessary (but you can’t do that unless you are already paying for the insurance and considered a “member”). So I’ve always had to pay for super expensive insurance on my own instead of getting cheaper insurance through my employer. I can’t risk having to pay for the medication out of pocket because then I couldn’t afford it.

    Is there a secret way to find out if an insurance company will cover your medication?

    1. MsMaryMary*

      I would go through your employer, not the insurance company. They should be able to look on a formulary and see if your medication is covered. If you’re working with a recruiter or hiring manager, they may not know. But someone in benefits should. If it’s not covered, benefits wouldn’t be able to tell you if an appeal would be successful. That is handled by the insurance company (or pharmacy benefit manager) and depends on your specific medical history and their criteria.

      I would also see if there are manufacturer discounts or coupons available for your medication. Sometimes you can greatly increase or even eliminate what you pay out of pocket, whether you’re going through insurance or not.

      1. Being Sick Sucks*

        I always ask HR/the benefits team first (just explain that I want help finding out if insurance will cover a specific medication), and they always just give me the insurance company’s customer service phone numbers and say to ask them.

        I do use a manufacturer’s discount program, but you can only use it if your health insurance covers the medication.

        1. MsMaryMary*

          I’m sorry, that sucks. I don’t know how senior or in demand you might be, but I would push back with benefits and tell them you have not had luck directly contacting the insurer in the past. I have looked up certain meds for my clients if they had a concerned new hire or if the company was changing insurance carriers.

          You could also try asking for a copy of the formulary, or which formulary the plan uses. If the pharmacy runs through a large, nationwide provider it might be publicly accessible. You may still be out of luck if the employer uses a custom formulary or a less public pharmacy administrator.

    2. Insurance Q&A*

      Argh I hate this so much for you. The medically necessary thing is the worst to get around.

      When you’re switching to a new insurance, see if your doctor can start the approval process before your insurance is active – often, you’ll be in the system with a “future effective date,” so the company can see your policy and do what they need to do before your coverage actually kicks in. If you work with your HR, they can also contact the insurance company in advance and say “Hey, I just sent over paperwork for BSS. Can you get them loaded ASAP? Their doctor is going to be sending over information for an approval for them.” You don’t need to go into detail with your HR, just that you need to be able to have an approval kickstarted, so could they get you added as early as possible.

      The other thing you can do is see if the insurance company publishes their medical policies on their website, and if they do, find the one that addresses your medication. Send a copy to your doctor as soon as you know who you’ll have coverage with. That way, your doc will be able to get everything in order and make sure as many boxes as possible are checked when they send over the information for the approval.

      1. LimeRoos*

        This last paragraph! Definitely check the website – I know ours (non-profit insurance company) has all of our policies and coverage guidelines online. I had to use it a lot when I was on the provider side seeing why claims were denied. You’ll want to look for coverage policies and/or reimbursement policies. They may vary per plan, unless it calls out specific plans in it, but it should give a good idea of what is covered, or if it’s not covered, what would make it covered – like, normally they don’t cover cosmetic surgery, but will in the case of breast cancer or skin cancer.

    3. Naturegeek*

      I have almost the exact same questions except about durable medical supplies. Finding out whether specific things are covered before one is a member should not be this hard!!

      1. Insurance Q&A*

        Agreed. Similar advice applies: See if you can get loaded into the system asap, then look at the insurance company’s medical policies with your doctor and get a request initiated as soon as you’ve got a subscriber ID number.

  35. Former medical biller*

    When I did medical billing, many years ago, most insurance reps, especially those at Blue Cross, Medicare, and Humana were super helpful at circumventing the ridiculousness and would usually hint at workarounds. United Healthcare and their 3rd party claims processors were the worst.

      1. AutolycusinExile*

        Add me to the chorus – all the health insurance companies I’ve ever had have been awful to work with, but United was FAR and away the worst >:(

    1. Insurance Q&A*

      ;) I’m always trying to train my people on how to get to a solution that’s the least work for everyone, even if it’s something they can’t say outright. Being helpful is kind of the job, in my eyes anyway.

  36. Sydney Bristow*

    Thanks for doing this!

    I know more than 1 person who had a baby and the costs for the birth wind up being billed to whichever parent has the earlier birthdate, regardless of whether the baby is covered on that person’s plan. One friend is going through this right now.

    Is there a way to prevent this from happening? When it does happen, is there a straightforward way to get it fixed? My friend has to keep calling over and over again explaining it repeatedly.

    1. Sciencer*

      In case you don’t get a response – there was an article on NPR about this not too long ago, could be worth searching their archive to find it.

    2. Insurance Q&A*

      First, congrats to your friend :)

      Coordination of Benefits is a beast, and there are so many rules at play. If the baby isn’t even covered on a policy, I’m kind of confused that the provider is even sending a bill to that policy…

      I would have the insurance company call the provider and lay out in very blunt terms what the baby’s coverage is, and where claims need to be sent. Possibly have them send the provider a letter – I’ve definitely done it in the past, though that doesn’t guarantee anything about a rep currently being able to do so.

    3. AVP*

      SO confusing. I had a baby this year and my husband and I are on different insurance plans, and we wanted the baby on his and not mine – talk about a confusing mess that I’ve had to explain over and over.

      My favorite part was that the baby’s entire hospital stay was rejected by insurance because the baby was entered at the hospital as “Baby Boy MyLastName” instead of “RealName Hyphenated-Name.” I had to literally take the baby back to the hospital with her birth certificate and be like, “you really don’t think we named him Baby Boy and you can just leave it like that, right?”

      1. LimeRoos*

        Oof yeah, someone should’ve definitely been following up/noticed the baby boy thing. I know we’ll enter babies as baby boy lastname before we know the name, but I don’t think bills get sent until we get confirmed enrollment. Because it’s ridiculous.

        For the birthday stuff up thread – they’re going by the birthday rule, whichever parent has the earlier birthday by day (not year – so 01/05/1987 beats 02/15/1985). The provider and insurance should be able to fix it with one call though, so you may have just dealt with not the greatest reps.

  37. Make Mine a Double*

    I would just like to second your comment that the people that answer the phone really do want to help you, and are generally good kind people. I recently had an accident where I sustained a head injury but was scared to go to the closest hospital without seeing if they were in-network first (yes. we know US healthcare sucks). I really wish I had a way to say thank you to Frank of BCBS for not only confirming they were in network and telling me the the maximum I could be on the hook for, but for telling me it would be ok, reminding me to bring my insurance card and mask, and asking if I had someone to take me. I ended up fine, and I wish I could have told him so.

    1. Insurance Q&A*

      <3 You can probably call in again and ask to leave a message for Frank's supervisor, or send in an email to that effect – we LOVE getting feedback like this!

      I'm so glad you ended up ok, and that you had an awesome rep help you out.

      1. Make Mine a Double*

        Oh, I can? I didn’t realize that, I just assumed I get send to a random call center. I will do that!

  38. Spotted Kitty*

    Haha, I went to the emergency room with excruiating pain in my side one morning at 3 a.m. By 7 a.m., they were putting me in a room and scheduling me for emergency gall bladder removal the next morning. My insurance claimed it wasn’t an emergency. I was like, “….um, they wouldn’t let me leave the hospital…” Luckily, they sent the same BS to the hospital, who disputed it, and then insurance magically covered (most of) it.

    1. Insurance Q&A*

      Yep, I see this a lot, and would love to ask what they think an acceptable alternative might be.

    2. PT*

      My state was one of the test states for this “you have to KNOW it’s an emergency before you go to the ER” and nobody cared until it kicked in on the BCBS plan that covered all of the state employees. Then the attorney general’s office suddenly became very interested in it.

  39. Anne Rogers*

    Wow, THANK YOU!!!! Question: is there a limitation of time on when you can perhaps get an insurance company’s help with a billing problem by a medical provider? I had an issue a few years ago that I am still mad about. I never thought insurance could help me? What happened was, I went in for a routine mammogram, which was covered. This was my first time getting a mammogram. The next day a nurse called me and said I had to come in again because the results weren’t clear enough. So I did. I assumed that was part of the routine mammogram and would also be covered. I was wrong and had to pay out of pocket for the retake, which was several hundred dollars. Could my insurance company have helped me with this? I think I asked and they said I need my doctor to change the diagnostic number, and I asked my doctor but she refused and said she legally couldn’t. Is there anything else I could have done? And is it too late to seek redress?

    1. MsMaryMary*

      There is a time limit. It depends on the plan and that state, but it’s generally 90-180 days after the claim determination.

      It’s also, unfortunately, unlikely your second mammogram would have been covered. Preventive care is covered at 100% under the ACA. However, as soon as a procedure or visit becomes diagnostic it’s subject to your plan’s usual cost share. If the unclear reading was a technical error (with the machine, or operator’s error), you might have been able to get the second covered. But if they wanted a second look for diagnostic reasons, then you’re stuck. If your doctor wouldn’t change the procedure code, then it likely was diagnostic.

      1. Not So NewReader*

        “The results weren’t clear enough” sounds pretty ambiguous to me.

        1. JessicaTate*

          My OB-GYN mentioned that often first-time mammograms come back “unclear” and you have to do a retake because the tissue is denser when you’re younger and they don’t have a history of scans to compare it to. (She mainly mentioned it as a “Don’t freak out when this happens” rather than raising the insurance issues, of course.) So, my guess is that MsMaryMary is correct and it wasn’t a technical error, but a diagnostic rescan.

    2. Insurance Q&A*

      I can’t say for sure if it’s been too long, but it’s always worth a try calling in now to see if they can help you out. At the very least, they can call the provider and ask for a coding review, which is a nice way of saying “hey we think this might be an error, can you triple check?”

      I’m so sorry you had to deal with this :(

  40. Lucille B.*

    Holy schneikes. Thank you for this post today – it reminded me I hadn’t sent out open enrollment forms yet!!

  41. A Genuine Scientician*

    Slight soapbox, but from my experiences dealing with prescription medications:

    Check out GoodRx; they will tell you what a particular prescription costs at a range of pharmacies near you. A lot of things are within a dollar or two of the same cost everywhere, but some things can be up to 5-10x more expensive at one pharmacy than another, and which pharmacy is more/less expensive changes per medication.

    If you have any expensive prescription, google “[drug name] copayment assistance program”. A *lot* of the pharmaceutical companies have copayment assistance programs which either drop the price outright, or which pay up to some total of your copayments per year, specific to individual expensive medications. I have one medication that has a list price of slightly more than $1,000 / month; with the free coupon card that doesn’t even have an income eligibility limit, it’s instead $30 / month. I have another where the pharma company is willing to pay up to $7,200 of my copayments per year on (and since I have a yearly out of pocket max of $3,000, that means I’m fully covered). How different plans handle those copayment programs varies, but often if you pay things up front and then get reimbursed by the assistance program, there’s nothing the insurance company can do about that.

    I *hate* that these things aren’t better known, and so they mostly benefit high educated people who likely have the incomes that they could afford these medications anyway, but this is the system we have, so I take any appropriate opportunity to let others know.

    1. A Genuine Scientician*

      (The original poster here sounds lovely, and I’ve actually had good experiences with the reps at my insurance companies, but despite the *people* being great, the *companies themselves* often aren’t.)

      1. Insurance Q&A*

        agreed 100% on looking for copayment assistance plans – I love in the prescription drug commercials (why are those a thing?) when they say “Company may be able to help with prescription drug costs.” My immediate reply is “yes, by lowering prescription drug costs….”

        And agreed – the people are working within the bounds of what the company allows, which often tie their hands in ways they wish wouldn’t happen.

    2. MsMaryMary*

      I tell people about GoodRx all the time, to the point where they think GoodRx is paying me to say so. I use it myself. They also show if you can save by getting 90 day fills or moving to mail order. GoodRx will also often link to manufacture coupons or discounts.

  42. Ask a Manager* Post author

    Received this spreadsheet from a reader who wanted me to share it on her behalf. She says: “I wanted to share a health insurance comparison I made for you to share with readers if you like. I built this to compare the options at my fairly large employer, but it also works for comparing plans across employers or on the marketplace. I used to be surprised that the high deductuble plan is a better value for me even though I hit my deductible most years, but putting the premium savings into my HSA more than make up the difference. I didn’t bother including the tax benefits or money market interest rates of an HSA, but they’re real too.”

    (I’m posting this unvetted)

  43. Naturegeek*

    I am stuck in a catch 22 trying to pick a plan on the exchange in my state- my DH has very specific type 1 diabetes supply needs and we want to find out if they will be covered and to what extent. When I try calling the insurance companies, they say they can’t tell us anything because we are not members…but I’m not going to sign on as a member until I know that they will cover his supplies! Is there any way around this? Is there some sort of dummy member number used for training new reps that might allow them to look this up for us?

    1. Insurance Q&A*

      Ooh! I might be able to help!

      Diabetes often qualifies for care management/case management programs, so you can reach out to the care/case management branch of the company to see if they can offer any insight.

      Also, pretending they can’t tell you things because you’re not members is nonsense. There are usually ways to access policies without a subscriber ID – though the reps you’ve spoken to may have forgotten that particular trick. If you call in again, ask to speak to a supervisor or escalation representative right off the bat. You’ve tried enough times that I feel comfortable advising to do this – and it’s a pretty critical question!

      1. Naturegeek*

        You are correct- we have tried several times with each company. Did try to ask for a supervisor once and the rep got all pissy with us! But we are stubborn and willing to try’s not like we can go without insurance. Thanks for the tip on the diabetes case management though- we will try that angle next!

    2. Hillary*

      Some states also have marketplace navigators who specialize in diabetes – they were great help to a friend’s family.

      1. Naturegeek*

        Unfortunately navigators haven’t been able to help, nor the state exchange reps: they both told us to call a broker but none of them have called us back. But I will poke around to see if there are any navigators who specialize in diabetes coverage.

  44. Sciencer*

    Thanks for doing this – your tone and enthusiasm is on track with what I’ve experience from insurance reps over the phone. I’ve been pleasantly surprised at how friendly and genuinely helpful they are.

    My question: Is it generally wiser to immediately follow up on a bill or other notice that seems wrong/concerning, or wait a while to see if it resolves itself first? I ask because I just had a baby two months ago and there have been numerous scary letters in the mail (during pregnancy and post birth) that had me running for the phone and spending stressful hours calling in circles to see what was up… when in the end what I should have done was wait a few weeks because the situation was resolved without my input.

    Specific example, sorry it’s a bit ranty: We got a letter literally the day we got home from the hospital that part of our baby’s NICU care was rejected as “not medically necessary.” We had no idea what this meant or what it would end up costing, and we took turns spending precious baby-sleeping time on the phone with insurance and the hospital trying to understand how they could have made that decision, what our options were, whether the hospital would appeal or whether we needed to do that, etc. We got different answers depending on who picked up the phone. In the immediate post-birth hormonal and sleep deprivation chaos, this process was genuinely more traumatizing than the birth itself. How did it resolve? On the fourth or fifth call to insurance, days before the deadline for filing an appeal (which we still didn’t know if we should do or not), the rep discovered that the hospital *had* in fact appealed on our behalf, the care had been approved, and we would owe nothing. There was not even a record anymore of the denial, despite us having two hard copies of it from two separate mailings. If we had known this would happen, we could have just waited a few weeks before following up to see where things stood, and saved ourselves a ton of stress. And yet, we have still never gotten any notice that the denial was reversed or that any of this happened; if we hadn’t called we wouldn’t know. So part of me thinks this is a lesson in letting things sit a while, and part of me worries that is exactly the wrong thing to do because you never know when some process needs to be set in motion.

    1. Insurance Q&A*

      Oh my gosh, I am so sorry you had this happen.

      I would have reached out immediately as well, especially because appeal timeframes are pretty tight. In general, I would default to that – it caused you so much more stress in this instance, but if your provider hadn’t been on the ball with the appeal, you would have been well-positioned to start it yourselves if needed.

      I mentioned in the post that I had to appeal a denial for a surgery – what happened was very similar to your scenario, except the denial got lost on my provider’s end, so I was VERY glad that I had kept on top of it.

  45. high risk*

    I recently went without a routine medical test because my in-network doctor told me that he could only order the test through labs that were on the preferred provider list for his brand of hospitals and doctors. But none of those labs were considered in-network by the insurance company. The insurance company did have in-network labs that could do the test, but when the doctor tried to order the test through one of them, the lab refused me on the grounds that my doctor did not have an account with that lab. One of the doctor’s labs offered me a “discount” if I self-payed rather than submitting the bill through insurance, but I refused because that just seemed shady and because I wanted all medical expenses to count toward my deductible. Should I have pressed my doctor more? Or the insurance company? Or the lab?

    1. Insurance Q&A*

      Your doctor could definitely have pressed the labs more. Or you could have asked your insurance company to lean on the labs.

      I hope you never have to deal with this again.

  46. Laurel Daly*

    Hi and thank you In advance.

    How do I get my doctor to actually bill my insurance company again?

    My employer changed insurance companies in October of last year to the purple square company you mentioned. When I transferred over there was an error and they didn’t Record my doctors name as my doctor.

    In December I called my doctor to renew my prescription and ask a question. In January I was billed over $600 for that call because they said I didn’t have insurance.

    I immediately got on the phone and called my insurance rep, my doctors Billing department, and a second medical group that my doctor bills through. After calling all of these numbers multiple times I finally got them all to talk to each other and my insurer agreed it was their fault and backdated my insurance to cover my doctor.

    All solved right? Except the next month I got another $675 bill from my doctor. When I called their billing department again, they said the Second medical group had to do the billing. That group says they need a new billing request from my doctor. And my insurance company says they can’t do anything until they get an actual bill. My doctors billing department says I should pay the 675 and get reimbursed from My Insurance company. My insurance company says that’s not the way it works they have to get a bill with the contracted amount.

    What are my Responsibilities and choices here?

    1. Ann O'Nemity*

      Commenting just to follow. We went through a somewhat similar “not my fault but I need to fix it” situation with insurance and I’m honestly curious about what to do.

      My husband had an issue where his birthday listed on the claim paperwork didn’t match what was in the insurance system – two of the numbers were transposed. The claim was denied. He tried calling the insurance and the provider multiple times to fix it and eventually exhausted the appeals process. It seemed like such a simple mistake and so easily fixable, but the insurance company never paid the medical claim.

      1. Insurance Q&A*

        In this situation, the doctor has to correct the claim. The insurance company can’t change anything on the claim form once it’s submitted, and they’re likely able to deny the claim at this point, even if it is corrected, for being outside of timeframes.

    2. Insurance Q&A*

      Oh what a mess.

      Call into the insurance company and have them do a conference call with you and the doctor’s billing office that the bill came from. Make sure that the billing office has the correct prefix and subscriber ID for you on file, and have the insurance rep provide the claims address to send a claim. Make sure during this conversation you ask the billing office to put your account on hold while the submit the claim to insurance.

      I’m assuming that your doctor is in network, so until the claim is processed by insurance, you *shouldn’t* have to pay anything. If they do convince you to pay by threatening to send you to collections or annoying you into submission, once insurance processes the claim the doctor’s office needs to refund you everything you paid above the patient responsibility you’ll see on your explanation of benefits. You may need to rope insurance in on this again, which is why I suggested having them initiate the conference call between you and the billing office.

      I’m so sorry you’re dealing with this. Good luck!

    3. MsMaryMary*

      I would try contacting your doctor, not their billing group, directly. A lot of times the providers are completely disconnected from billing. Directly telling them something like “I don’t want to have to find a new doctor, but I can’t afford to keep paying $600+ for every visit.” may work.

  47. deanbad*

    Hi! I work at a super small business (few than 10 employees) and our health insurance is…fine? But expensive. So expensive. I’m relatively new to the workforce and this is my first time paying for my own insurance. Is it normal, at 60k/year pre tax salary, for my insurance to cost $1200 a month? My employer subsidizes part of that, but still, that’s $300/pay period deducted from my paycheck! I didn’t grow up in a household where we HAD insurance and I don’t really know or understand what my options are.

    1. Insurance Q&A*


      Yeah, that’s a pretty standard premium, unfortunately. You can check out individual market options to see if they’re more feasible, because sometimes you can get an income-based subsidy, but insurance is expensive. I wish I had a better answer :(

  48. Generic Name*

    This is so awesomely helpful. Thank you!

    I want to mention to folks to not be afraid to call your insurance company to ask for help. My son was recently diagnosed as autistic, and there’s a bunch of therapies available. I had a really difficult time finding a place that was in-network and was also accepting new patients. It was taking me literally hours of work calling, emailing, and filling out massive questionnaires. I finally called my insurance and asked for help in finding a provider, and within about a week my son was “in the system” of a new provider and we had an assessment set up. Unfortunately, I’ve found insurance companies website’s lists of who is taking new patients, or even who is in-network to be out of date or just darn near impossible to navigate, and calling is so much more efficient.

    1. Cat Lover*

      “Unfortunately, I’ve found insurance companies website’s lists of who is taking new patients, or even who is in-network to be out of date or just darn near impossible to navigate, and calling is so much more efficient.”

      Yep. My company stopped taking a certain insurance as of April 2020 and we are still listed as in-network on their website. It’s very frustrating for everyone.

      1. Insurance Q&A*

        Yep, getting the websites updated is really… lengthy. I basically ignore the “accepting new patients” indicator on the web lists and call in to verify.

  49. Esmeralda*

    My son has a slow growing cancer that has, over the years, stopped or even shrunk, sometimes for several years, but does start growing again. (Stupid cancer). So, as the mom, I say THANK YOU for this explanation. Took me a few years to learn it.

    I’ll add a couple of suggestions.

    1. Yes, you are stressed and upset and angry. Try really hard to keep it under control. The insurance company rep is a person too, and THEY did not make the decision about denying a claim. The calmer and especially, the more polite, you are, the more likely the rep will go that extra mile for you. Say thank you, and always fill out those customer service surveys when someone has really been helpful. Or even just sympathetic.

    2. Ask the rep for the names and contact info of people they think can help you. (Pro Tip: Get the direct number, even if the rep will transfer you, just in case)

    3. Your provider may be able to talk with the insurance company for you.

    4. Take notes and include the date and time. Write down everyone’s name and number that you speak with. Don’t be afraid to ask someone to repeat what they said, to spell out words, etc. Recap before you hang up

    5. Follow up and/or move up the food chain if you don’t hear back/ get the result you need.

    6. Don’t be so polite that you never put someone on the spot.

    True story to illustrate some of these. My son was prescribed an anti-emetic, monthly prescription. Worked great. Problem was, a month = 28 days. Talked to the nurse, who suggested talking to the hospital pharmacist. Pharmacist couldn’t help, referred to insurance provider. Talked again to the nurse, who said, you all are coming in tomorrow, let’s call Large Insurance Company then. Nurse calls insurance company with me sitting alongside, gets booted around, finally gets someone who can make a decision. Decision is we’re so sorry, but that’s how the drug is dispensed, there will just be a couple days lag. Finally nurse says, ok, I’d like you to talk to the mom right now and tell her it’s ok for her 8 year old to vomit for three days straight.
    I did not need to talk to the insurance guy. He came up with a solution:prescribe a pill with twice the required amount, cut it in half, dispose of the leftovers at the end of the month. Because the pills were the same price regardless. Yep!

    1. A Genuine Scientician*

      All these tips are great, but I just have to echo #1 really hard.

      The fact that I do not yell at customer service reps for things that are not their fault feels like it might as well be a superpower.

      Calmly saying something like “I know this is not your fault, you did not cause this, but I need to get this resolved”, and *maybe* adding something about it being a frustrating/scary/etc experience and I’d like to apologize in advance if I get emotional seems like it has gotten customer service reps in so many industries — insurance, airlines, banking, ISPs, etc. — to go well out of their way to handle things. It actually makes me feel bad, because if they’re going this out their way to help me just because I’m not being awful to them about something that is obviously not their fault, what must they be being put through by so many other customers.

      1. DKMA*

        One thing I hesitate to add, but think is important. You will get a range of quality in the people you talk to. If you do it long enough you will figure this out.

        Stay polite even to the people who just aren’t very good at helping, but don’t hesitate to cut bait and call back hoping to get a better person or escalate to someone else if what you are hearing isn’t making sense.

        My company also had some sort of “important customer status” with our insurance at one point so that there was a dedicated team of troubleshooters that were awesome, if you work with a big company it might be worth asking HR if your company has something similar if you’re stuck in a particularly thorny situation.

        1. Esmeralda*

          Yes. And it’s worth asking a really helpful rep, can I ask for you if I have more questions/ need more help. Sometimes you can, and the you’re golden (blessings on Nora at Big Medical System, who 10 years ago helped me outmaneuver inept Big National Laboratory Provider and the associated insurance claim disasters).

        2. A Genuine Scientician*

          Yes, I’ve definitely hung up and called back in hopes of getting someone else. Not so much in my health insurance as a few other things, but I have absolutely said “I don’t think this is getting us anywhere; thank you for your time,” hung up, and hit redial.

          I like to imagine that I must have just caught them on an off day. I have no way of knowing that it’s that, rather than them being fundamentally bad at a part of their job, but I have no way of knowing that it’s *not* that, and assuming that they’re just having an off day leaves me in a better mood, and less likely to snark at the next CSR I deal with.

          1. Insurance Q&A*

            Yeah, Officially I’m keeping my lips zipped on this one, but…

            Unofficially, cut bait and call back until you get someone who can help you.

  50. I'm just here for the cats*

    Hi OP,

    I have a dental insurance question. I have to see an endodentist. There are only 2 in my area and only one that is covered by my insurance. I have a really bad tooth but I have had to wait almost 3 months because the provider that is covered is so backed up. It’s a moot point now since my appointment is in just a few weeks. But would I have been able to contact my insurance and see if there would have been an exception that could be made?

    also, why do insurers choose only certain doctors, especially when options in a certain area are limited?

    1. Insurance Q&A*

      You could have called in and asked for an exception, or to see what the out of network coverage would have looked like. Sometimes on the dental end, it’s not a huge difference.

      I’d also like to shout out a product called DentalSolutions by DenteMax, which is a discount program for dental services. It’s not dental insurance, but it can really reduce the costs of dental care. Here’s a link:

      For how providers are chosen… There are a lot of moving pieces. Often, it’s a mix of providers reaching out and asking to join the network and the insurance company seeing a provider move to the area or have a high volume of patients and reaching out. Insurance companies look at credentials (licenses, etc), reviews, quality, ethics, and a whole bunch of other things to make sure that the provider is one who they want to have in network, then the provider and insurance company come together to negotiate a contract. Providers do their due diligence as well, looking at reimbursement rates, reputation, ease of use and payment, quality, etc, so it’s not just a one way street.

    2. MsMaryMary*

      Dental is different from medical, and unfortunately this kind of problem is often a provider problem more than an insurance company problem. Occasionally, some providers (usually dentists who have been in practice for a long time) don’t participate in in many, or sometimes, any, networks. Some have decided it’s easier, and/or more lucrative, to bill patients directly.

      A network provider has agreed to accept the insurance company’s price for a certain service. So, let’s say Insurance Company A will pay $100 for a simple filling. Your cost is usually something like 20% of that $100 up to your annual max (once you hit your max you are responsible for any additional charges, unlike medical) But maybe Insurance Company B will pay $120, so your dentist agrees to be in network for B but not A.

      But maybe your dentist is fine with getting $100 and doesn’t want to mess with submitting claims and procedure codes, so they don’t agree to be in either network. Or, maybe the dentist knows they’re the only provider nearby, or have cultivated a very loyal client base, and they’ll charge $200 knowing neither insurance company would agree to pay that, but their patients will.

      You could try having your insurance company and seeing if they’ll contact endodontist #2 and ask him to be in network. Sometimes a carrier has changed their reimbursements or something else, and the provider just needs to be asked.

      You could also contact endodontist #2 and ask for an estimate. Get it in writing as a formal estimate. You could have them submit an out of network claim. They may agree not to bill you the difference between the insurance company’s rate and what they want to charge (which is called balance billing). Or maybe the cost difference isn’t significant enough to balance out waiting 3 months to see the other endodontist.

      Good luck!

    3. ABK*

      I can answer your last question, not the first:
      Insurers create networks so that they can negotiate preferable rates with providers they reimburse. Like a general contractor only using their preferred electricians, plumbers, painters, etc and pressuring those networks to offer discounts. There’s a growing trend of insurers narrowing those networks even further so that they can also control the “quality” of care. How do they control the quality? IDK, that part is yet to be determined, but it’s things like keeping referrals within a certain circle, working with providers so they understand how things are supposed to work, generally trying to be a close partner instead of just a PITA.

      The corporate suits putting together the networks might overlook more rural areas with limited options! They look at their members and their networks and generally conclude that yeah, access is there! But wait…it’s a little swiss cheesy, oh well, that’s only a few members and they have that one practitioner over there. no prob. good enough. The other practitioners in your area might honestly have trouble getting network status if the practitioner is small and the insurer is gigantic.

      Sure, you could have called and asked. They might have an override policy if access is limited.

  51. Lady Kelvin*

    I just want to reiterate the fact that many health insurance companies offer other benefits. Ours offer membership to a variety of gyms for $200/year, and if you go 45 times in a year its free. Its awesome and both my husband and I usually get free memberships. In the years we don’t, $200 is still way less than the monthly fee from the gym.

    1. noahwynn*

      Yes! Our old insurance at work had the best gym options. I think it was $25 per month and you could go to any gym on the list at any time. If I wanted to go to the LA Fitness by work one day and the Anytime Fitness by my house the next I could. There were options nationwide if you were traveling.

  52. I'm just here for the cats*

    Have another question.

    This might have been because at the time I was on state medic aid, as I was underage and parents didn’t have health insurance and low income. This was also about 15 years ago, so maybe things have changed.

    I have a specific medical problem and for a while I had to have a specific medicine created at the clinic and they would mail it to me. I lived in rural area and the small town pharmacy couldn’t provide what I needed. Something happened and I never received my meds, but the insurance was billed. We tried tracking it down but the clinic didn’t have a tracking number (stupid, I know) and the post office said they couldn’t do anything. Even spoke to the post man (again small town so he knew us) and he didn’t remember having a package.

    Basically what happened was the insurance wouldn’t pay to replace the medicine, because they showed that it was given to us. So we had to drive up to the clinic and pay out of pocket to get my meds. This is why I will NEVER do mail ordered medicine.
    I’m wondering though if there are procedures in place for situations like this. So if someone called you and said that their meds were stolen or lost in the mail, could you do something?

    Similarly, until my current job with insurance (which is amazing!) 2 different employers and different insurance companies kept pushing mail ordered pharmacies. I had to pay more to get my meds at my local pharmacy because they wouldn’t cover as much as they would if I did it through the mail in program. They would only make exceptions for emergency meds and things like antibiotics. Why do this to people? Especially since I’ve had bad experiences and my medicine is life-threatening if I stop abruptly taking it. If my meds were lost in the mail or stolen, and I couldn’t get new meds I would probably end up in the hospital in a few days.

    1. A Genuine Scientician*

      The one time I had a medication lost in the mail (mail order pharmacy said it was delivered, but it wasn’t in my mailbox or at my door) about 3 years ago, I called the mail order pharmacy and asked about it, they had me fill out a form and send a copy to both them and to my insurance, and they sent out a replacement refill at no charge to me. Since then, I’ve preferred to have that particular one delivered to the brick-and-mortar pharmacy I use (which the mail order place will do at no extra charge), just in case it were to happen again. It might be worth asking your mail order place if there are any pharmacies you can have it delivered to for no extra charge.

      1. Insurance Q&A*

        I like that workaround.

        Many employers/insurers are pushing mail order pharmacies because it’s cheaper. Usually they work ok, unless for some reason the post office experiences any difficulties in handling mail in a reasonable way. Not that that’s every likely to happen.

        Personally, I pay the extra to pick up my meds in person, but my meds are cheap and it’s not a financial burden to do so. I know plenty of people for whom it IS a burden, so they are at the mercies of the mail.*

        *go USPS I love them they’re great and do the best they can within their system limitations.

      2. I'm just here for the cats*

        Thanks for that info. I’ve since changed jobs and my insurance is a much better one now and doesn’t have this requirement. I had talked with an insurance rep and she blew me off and said that if I didn’t want to pay more I would have to go the mail in route.

  53. AVP*

    This is so helpful!

    One thing I’m curious about – are there any standards about *how* things get billed? Asking because I recently received a medical bill via a *text to my cellphone* from a major hospital group which has both my insurance information and an address where they can send me a real bill. It seems so unprofessional that I just ignored it, tbh. (It was small and I promise not to let it go to collections, but wth, now I have to manage their billing process from my phone, too? Can they not afford a stamp?)

    1. Insurance Q&A*

      I don’t believe so, though billing by text is new to me. I would reach out to the hospital and request that 1, they stop billing by text because [everything you said], and 2, that they send you a paper or electronic bill, whichever you prefer.

      1. Ben Marcus Consulting*

        Best practice is to let people self-filter. I introduced pay by text to my Medical Groups July 2019 and within 20 days, 45% of our patient statements were paid by text. Every solution I’ve seen allows for the patient to travel to a PDF copy of their bill with little to no friction (little friction = you need to log into, or set up, an account; no friction means that the URL itself is the log in and is single time use). Almost every solution offered the option to receive by another digital means or to have the statement mailed to your home (and sometimes a combination!).

        While it is a newer concept, it isn’t inherently unprofessional or at least no more so than appointment confirmations/reminders via text.

  54. Bratmon*

    I know people who have had problems with out-of-network doctors billing them from an in-network hospital without any way of knowing they were out-of-network. Is there a way to know whether or not parts of your treatment will be out-of-network before you get the treatment?

  55. Case of the Mondays*

    If you are writing an appeal, try to show how your denied treatment will save them money. For me, I had a procedure done that is normally cosmetic. I explained what that would cost versus the multiple surgeries I would need if I did not have it done. I also provided medical literature showing that this off label treatment worked. It was approved!

    The shady part is the doctor that agreed to do the procedure (which required multiple sessions) didn’t want to do anymore after my insurance approved it. That’s because he had to accept the insurance rate and not the out of pocket rate I had pre-paid. So I had 3/4 of my procedure done which was enough to apparently work.

    I could have reported him to my insurer but I didn’t want to be treated by a doctor that didn’t want to be treating me. I couldn’t go elsewhere easily as this was an off label treatment I had to convince a doctor to do and an insurance company to cover!

  56. Minta*

    thank you for offering all of this great information. Very interesting and helpful. My insurance offers what they refer to as a feature where a case manager or nurse calls me after many medical visits. It’s happened after ER visits and regular office visits. It’s like to check up on me or my spouse and dispense advice or something? It often feels like they’re calling to tell me I should’ve went with this or that lower cost option. Hard to deal with because 1) it’s an unsolicited phone call and 2) I feel like I’m going to get gently scolded about my healthcare/medical choices in the name of saving money. It was sometimes already difficult to seek the help I needed in the first place, and I’m not looking forward to a replay or discussion of it. Am I being unreasonable? Is it worth taking these calls or calling them back? Thanks.

    1. Insurance Q&A*

      It’s entirely up to you. If you’re looking at a complex care situation where you’re going to be juggling lots of different providers, medications, appointments, etc, case management can be really helpful and really be on your side, making things easier. They’re probably calling to suss out if case management would really benefit you, and if you get even a whiff of being scolded you can just end the call. But I also understand it being Too Much, so it’s really up to what you can handle at that time. Maybe wait until things are less stressful, and then reach back out?

    1. Insurance Q&A*

      Hospitals are now required to list costs on their websites :) You can also call your insurance to find out what your coverage is, and what your out of pocket max is.

      1. fhqwhgads*

        So, um….what do you do if the hospital got hit with a ransomware attack and their website is offline for the foreseeable future? Only option to find out the out of pocket max and assume it’ll be that? Sincere question.

  57. just a small town girl*

    I’m trying to decide if it’s worth it for me to purchase my company’s dental insurance even though the provider I see is not in network. I’ve been paying out of pocket cash price through my FSA for cleaning and X-rays because it’s cheaper than the plan premiums but I’m having a premonition that I will need real dental work done soon so I wanna get back under insurance, but nobody can tell me how much roughly procedures would cost me for an out of network cost if I get the insurance(since I’m not a current subscriber I can’t access the insurance’s help) and it’s driving me up a wall. So kudos to you for dealing with this every single day! LOL

    1. DKMA*

      In my experience heavy dental work is barely covered in network with dental insurance, I’m betting it will be even worse coverage out of network.

      Not an expert, but my understanding is that dental insurance isn’t like normal health insurance. It’s more like a discount program that you pay for up front than it is actual insurance against things going very wrong.

      1. Insurance Q&A*

        Dental insurance is definitely a different world from medical. Give the dental insurance company a call and see if they can talk you through coverage – I’ve been increasingly seeing truly decent plans.

        Either way, may I introduce you to Dental Solutions by Dentemax? It’s not insurance, I don’t get paid by them for anything, but it’s an excellent discount program that can help out quite a bit. Here’s a link!

      2. Tired of Covid-and People*

        Yes. If you can’t get a dental plan with an unlimited maximum, it will unlikely be worth the monthly premiums if you need major work done.

    2. Texan In Exile*

      For really big dental work – implants, root canals – go to a dental school if you can. Great work and very inexpensive.

    3. JessicaTate*

      The other thing I recently learned is that some dental insurances have a waiting period for full benefits — sometimes over a year to get the max % discount on procedures beyond preventative. (This was on the private market, not an employer plan.) Basically, they’re trying to avoid people signing up when they know big work is coming; they want your premiums during the preventative-only years before they give you the real coverage.

      And I agree with someone else, the coverage for out-of-network is usually really, really pitiful. It’s probably not worth it.

      1. Tired of Covid-and People*

        Read the fine print! Some dental plans will not replace teeth that were missing before you became covered under their plan!

  58. Here we go again*

    Allison, will you please do another one of these for retirement plans? This was great.

  59. Tobias Funke*

    Thank you for doing this! I am a provider and dealing with insurance is the most stressful part of my practice.

  60. Lurker2209*

    I’d love to see a primer—from anywhere—on primary and secondary insurance. My medically complex child has primary insurance through my spouses’s job and secondary coverage through Medicaid. The Medicaid is a lifesaver, but it’s contracted out through a private company.

    Well the primary insurance only works with one speciality pharmacy in-network and the secondary only works with one speciality pharmacy in-network. And those are not the same pharmacy! I spent hours on the phone with the pharmacies s d both companies. Finally I just paid the balance out of pocket on my credit card and had to submit it to the secondary insurance for reimbursement.

    And all this for an injection my child needed every month!

    There should have been a better way

    1. Insurance Q&A*

      Oof. Multiple insurance plans could definitely be a piece in and of itself. I agree – there should definitely have been a better way. I”m sorry that was such a hassle!

  61. DKMA*

    One extra thought for folks, sometimes issues you run into may be the fault of the plan design, in that case it’s worth escalating with your company, who ultimately chooses the plan designs. It won’t likely help with an immediate situation, but could with something chronic or for future issues (for others).

    This worked with me when I found out my son’s therapy for autism wasn’t covered by the plan. I ended up having to buy an individual Obamacare plan for him because it was cheaper than paying for the services directly.

    I had asked questions of HR partners while trying to figure out if it was covered originally, and had expressed disappointment at that time. I later included feedback in our companies annual employee engagement survey. It ended up getting added in the next plan year, and my contact in HR reached out to let me know saying my feedback had helped give it visibility during annual benefit reviews.

    Note: I intentionally put a lot of identifiable information in the engagement survey so HR wasn’t being shady by letting me know it had been seen.

    1. Insurance Q&A*

      Yep, often if something isn’t legally required to be covered, the decision to cover it or not is up to the employer. If you want something covered on your plan, talk to your HR! :)

    2. Ann*

      I complained to my company when they changed their insurance policy to exclude a certain procedure (abortion). They didn’t care about my opinion. When I quit, I cited that exclusion as a key reason. I’m not sure if they cared then either, but it felt good to say it to them. I’m happy that 100% of the staff in my previously 10 person office has also quit since then. I’m sure not everyone had the same reason, but I think that they extent to which they expressed to me how little they cared about my opinion on that topic was an indicator of how little they cared about employee satisfaction overall.

  62. Longtime Lurker*

    This is super specific and I think I need to make a phone call, based on what you are talking about, but I took my teen to the doc for difficult periods and as part of the workup she did an STD test which she said was her standard policy with teenagers and I was fine with and our insurance company denied it all, saying STD testing is not required for the stated reason we were there. Based on your answers, I feel like I can fight this one (it was a $250 bill, btw, which isn’t awful, but still)

    1. Insurance Q&A*

      You can very likely challenge that. Most STI tests are covered under the ACA, too. I can’t say one way or another without seeing the specific codes, but you can definitely ask about that as well.

      Make sure you have a PHI/HIPAA authorization on file when you call in – STI/STD sometimes has tighter HIPAA protections than the general ones that activate at 18yo.

  63. Jessen*

    Is there a way to argue for an insurance company that their in network services aren’t actually adequate when they say they are? So an example might be, if I’m looking for someone who does specifically trauma therapy. My insurance covers a number of therapists who say they treat trauma alongside a number of other things, but none of them have any specialized training in trauma therapy. These therapists also charge much, much less than a therapist who has specifically done training in trauma therapy.

    Now the problem on my end is, the insurance company is saying a therapist who may have at most taken one class on trauma during their education is effectively equivalent to a therapist who has significant specialized education on the topic. They won’t pay out any more than what the first therapist charges and they won’t consider any extra benefits for being out of network because they have therapists in network who handle trauma. And we’re talking the kind of difference that could be a couple hundred per session.

    Is there any way out of this? I’ve found it’s a major problem in mental health care because the insurance networks do not differentiate between someone who does a particular issue on the side (and often isn’t very good at it) and someone who specializes in that same issue. You get a set of therapists who take your insurance and list like 2 dozen different disorders as things they handle and that’s supposed to be sufficient for handling specialized needs according to the insurance company.

    1. DKMA*

      Yes there is a way to do this. I wish I knew the details because my wife dealt with this for speech therapy for my autistic kids. The in network providers were all either different specialties or 40 minutes away, longer at rush hour.

      We were able to get an exception where the out-of-network provider was treated as an in-network provider. Note: This did not include the benefit outlined in the original post of the provider being held to an “allowable amount”. But our insurance paid at an in-network rate, and it hit our in-network deductible and OOP maximum. $16/week balance billing was feasible where the alternative was no speech services or what was looking like $100/week out of pocket before we got the exception.

      1. DKMA*

        Edit to add: It’s POSSIBLE, doesn’t mean it’s easy or likely to happen. We had to go through each of the people in our service area and identify why they weren’t appropriate, which wasn’t hard for our needs, but you may need to get documentation from “in network” providers that they are not appropriate for your needs.

        We also had to follow-up every other month or so and get them to fix charges they inappropriately classified as out-of-network and repeat the authorization every 6 months. My daughter’s individual therapist left and a new in-network practice finally opened in our area so we don’t need to play this game anymore.

        1. Insurance Q&A*

          Eek my comment vanished.

          yes, it’s possible. Like DKMA said, it’s likely to be a lot of legwork, but ESPECIALLY for trauma therapy you want to make sure you have the right person.

          The phrase you’ll want, most likely, is “in-network exception” when you initiate the request. Good luck!

        2. Jessen*

          A follow up question if anyone knows.

          Is it a problem if the in network providers say that they are appropriate? Much of the issue with mental health is you get a lot of therapists who claim a wide range of areas they can practice in and aren’t really qualified to do most of them. I (and a lot of other people with complex trauma) have found it’s a routine occurrence for a therapist to claim that something like a standard CBT treatment is appropriate for trauma. I’ve also dealt with stuff like, say, finding a single in network practitioner who turns out to be homophobic or something and of course doesn’t see any reason why that should be an issue.

          1. DKMA*

            So from my experience it was not a super precise process, my wife noted that they needed to be specialized for our kids needs and there was a very short list of people to go through (half of whom for some reason had home rather than office addresses listed).

            My guess is you’ll be somewhat at the whims of bureaucracy, but if you can clearly articulate barriers that make therapeutic sense you have a chance. We ended up eventually getting a customer service rep who listened to our concerns and helped us submit for it in a way that worked.

            If you find someone empathetic they will likely help you.

  64. Red Reader the Adulting Fairy*

    I review medical coding and denials for ED and outpatient claims for a large hospital system. In general most of this is spot on, but I will observe that in my experience, it is common for insurance companies to give one set of explanations as to why something wasn’t covered to the patient, and a fully different explanation to us as the providers. There is one particular big nationwide ins co that is the absolute worst pain in my professional tailfeathers because of the totally bizarre things they pull.

    1. Insurance Q&A*

      Yeah, I see that as well. Clinical edits, specifically, are a big culprit in this area.

  65. Insurance Q&A*

    Alright peeps, it’s been a blast! I’m calling it a night.

    Thank you everyone for your questions, and it made me so happy to see everyone supporting each other and sharing wisdom and experience. I hope this has been helpful :)

    Til next time,

  66. A Different Insurance Co. CC Trainer*

    I am also a customer care trainer at an insurance company, and I love this post so much! Especially the last bit. Earlier today I legit got legit teary-eyed discussing the importance of their job with our phone reps.

    The other item I’d add is that in the US, 90% of the things that annoy you when you call in are either HIPAA mandates (with a phone rep worried about violating HIPAA mandates and being extra cautious–it is a VERY big deal if they violate HIPAA) or a federal mandate if you have a Medicare or Medicaid plan. The remaining 10% of the insurance company, but they really have very little control over procedures with federal programs.

    1. Insurance Q&A*

      Hi fellow trainer! Seconding everything about HIPAA, oh my gosh. We didn’t have space to do HIPAA or COB justice today, but maybe someday… lol

  67. JB*

    My husband and son go to chiropractor who doesn’t take insurance, so they pay 100% themselves. After wondering about this for years and (neither of them doing any research), I called the insurance company to find out if there is any way WE could file the amount ourselves and get some reimbursement from insurance.

    Chiropractic services are covered. And a primary care doc is involved. (So we could get a referral.)

    Lots of disclaimers about might be out of network, only a %, etc. but – bottom line – YES, there’s a form to download from their website. Send it in with receipts. My husband still doesn’t want to bother with it. :-(
    However, it’s nice to know there IS an option.

    1. Insurance Q&A*

      Yes, you should either be able to be partially reimbursed or at least have it applied toward an out of network deductible until you meet that and can be reimbursed. You can probably snag his receipts and submit on his behalf, just saying…

  68. Raincoaster*

    I’m Canadian, so most of this doesn’t apply to my healthcare specifically, but it’s still a darn good guide to navigating a bureaucratic process. The part about responding/appealing in the same language they use…well I’m appealing a bureaucratic ruling and will be using these tips.

  69. Anon Supervisor*

    I’ve worked in medical billing fo 20 years and my biggest piece of advice is to call your insurance company before you have anything major done to see if you need an auth, if the hospital is in network, or if your procedure is even a covered benefit (a lot of speech therapy is not covered unless you’ve suffered an illness or injury and some drug therapy is not covered for off-label usage). ALSO, prior-authorizations do not guarantee payment for some plans. If you have an authorization for a certain chemo drug, but all of a sudden it’s denied as not medically necessary, call your insurance company to make sure the provider coded it correctly. It’s possible they used an incorrect diagnosis code or used the wrong procedure code. It’s possible that some plans require additional documentation, such as lab results, in order to pay your claim.

    1. Insurance Q&A*

      Agreeing with all of this, especially prior auth not necessarily guaranteeing payment. Prior auth is just the insurance company agreeing that the service is medically appropriate.

  70. Office_worker*

    I have received multiple incorrect medical bills. (My favorite was for my baby’s circumcision when he had not been circumcised. Very easy to prove the bill was incorrect!) Every time, the insurance company has been very helpful in resolving the issues, and they always make me feel like they’re on my side. Insurance sucks, but the customer service is actually great in my experience.

  71. Texan In Exile*

    Be careful if you choose the option with the copays. BC/BS of Michigan uses doctor office location to determine if something is an office visit or a hospital visit.

    That is, even if you go to a doctor’s office for an office visit, if that office happens to be in a hospital, BC/BS MI considers it to be a hospital visit, with the $700 deductible, not an office visit with a $45 co-pay.

    All because the doc has her office in a hospital.

    (United HealthCare does not do this.)

    (I am still bitter about this and hate BC with a passion.)

    (I worked for a health insurance company early in my career and we didn’t pull this crap.)

    1. Insurance Q&A*

      Yeah, my company doesn’t pull this nonsense either, but the advice is sound. Definitely check to make sure the location where you’re going to see your doctor is in network, and how it’ll be covered.

  72. Jessica Fletcher*

    “Department of Financial Services” might instead be Department of Insurance or similar, depending on your state. It’s DFS in NY, but not everywhere. You want the state office that regulates insurance companies.

    If you reach out to an elected official for help, call their district/local office. They have staff dedicated to handling constituent problems!

  73. Video Interpreter*

    I’m a video interpreter with a VRS company and we call many, many insurance companies. Does your workplace include any training for reps about relay services, how to handle calls with an interpreter, deafness, etc?

    Most representatives are very nice, but even the nice ones will refuse to speak directly to the deaf caller (“tell the patient that they need to ___”), say offensive things about deafness, or make the deaf caller jump through hoops to prove their identity in ways that I never experience when I’m calling for myself. I’m just wondering if you had any thoughts.

    Thank you so much for this, by the way. I didn’t know case management was a thing, off to call my insurance company now!

    1. Insurance Q&A*

      I definitely talk to my classes about best practices when working with interpreters and relay services, but I’ll spread the word more broadly! Thanks for prodding me on this.

  74. Anon for this*

    No sure if you’re still posting here since it’s been a couple of hours, but I’ll ask just in case. Any recommendations for appealing an insurance company’s decision to deny payment for anesthesia because they said it wasn’t necessary? In a case where the person involved was told that because it was a more challenging (although out-patient) procedure, he or she was going to be knocked out? What proof can you give other than, “The doctor said I had to be knocked out so I was”? (I would also like to add snarky comments asking if the insurance company decision-makers would enjoy having surgery without anesthesia, but I will refrain.)

    1. Insurance Q&A*

      I definitely concur with the snark.

      When you initiate the appeal, basically saying what you’ve said here should be fine. They will then reach out to the doctor for records, so you can give your doctor a heads up that you’re going to initiate the appeal and what you’re going to say, so they can get their ducks in order for when the request comes through.

  75. Scarlett10is*

    Wow! What amazingly helpful info, thank you! Did not know this type of accessible assistance navigating the quagmire of US healthcare was a thing.

  76. Grizabella the Glamour Cat*

    This one sentence absolutely blew my mind: “Also, I can guarantee that the vast majority of phone reps you talk to will want to help you.”

    The idea that insurance company representatives actually want to help me is something that never crossed my mind. I’m a little embarrassed to confess that I’ve always thought of insurance companies as the “bad guys,” faceless entities whose goal is to deny anything they possibly can to protect the company’s profits. I assumed that the reps were under pressure to support this goal, regardless of whatever their personal views might be. After reading this, I’m realizing that I don’t necessarily need to be that cynical. What a concept!

    This piece has given tons to think about. Thanks for all of this, Insurance Company Rep (I wish I had a name for you, because that sounds too impersonal), especially for giving me a different way of looking at things.

    1. Insurance Q&A*

      <3 my pleasure!

      Just pretend it's me every time you call your insurance company lol

  77. R*

    I don’t have time to wade thru all the bills and match the eobs (trust me, those eobs are wrong all the freaking time! :sob:) and figure how to pay who whatever amount plus track how much is in the HSA at this point in the year… We both work full time and have two kids and one is medically complex aka expensive. Every plan is a high deductible plan at our jobs, and the employer contribution is peanuts (would really love to know averages by state, industry, employer size, etc on what percent they contribute btw). I’m so far behind on the med bills I can’t bear to open the mail anymore. What are they gonna do, repossess a kid? I have lost my GAF.

    SO– the question is, is there anything out there that helps ordinary people who are overwhelmed keep up with all this? That would help make sure I’m being charged what I should do I can pay it without getting taken to the cleaners?

    1. Insurance Q&A*

      Yes! See if your insurance company has a case or care management program, or even a concierge service where a phone rep is dedicated to helping you untangle everything. Larger hospital systems often also have patient advocates who help with this.

  78. NoRealNameHere*

    I wish this person had been at my health insurance provider’s company. They denied my 5-year-old’s ER bill because they said it was a workers compensation claim (you cannot make this up). I fought them for 8 months to pay that bill, they finally did but it almost got sent to collections and took up many, many hours I don’t have.

    1. Esmeralda*

      Yeah. We had one period where my son’s claims were rejected because of various mismatches between his actual identity (10 year old boy) and info on the claim (infant, 80 year old woman, incorrect procedure, incorrect medication, wrong name, wrong address). We also received bills for other patients (inside envelopes addressed to me). We had to laugh — how old is the boy today? And then off to spend hours on the phone. Really, that’s half of how I used my FMLA time—half taking care of the kid, half dealing with insurance/doctors/various lab service providers/ pharmacies… And also the 504 paperwork for school.

      1. Insurance Q&A*

        *facepalm* I am so sorry you both had to deal with that. That is Absurd. Kafka-esque. Abhorrent. I hope you never need to experience it again.

  79. Talula Does The Hula From Hawaii*

    While i’m not American (despite the username) thanks for posting all this, its interesting to know and it will be very useful for anyone navigating the system.

    1. Insurance Q&A*

      Haha your username is most excellent.

      My pleasure :) i hope it’s helpful for anyone dealing with a bureaucracy in general, despite being specifically tailored to this one.

  80. Woah*

    I’ve been covered under my husband’s insurance, and we were paying for fertility services out of pocket since his insurance doesn’t cover them. I got a new job with insurance that covers fertility, 10% copay up to 25,000, after my 1500 dollar copay. This is vastly better than our out of pocket expenses, so I’m happy, but the rest of the new job’s plan is kind of awful- 100 for an office visit, 150 for urgent care, etc., versus my husband’s HMO, which is 10 dollars for an office visit, 30 for urgent care. So I’m double covered, and both insurance companies know about each other, but they tell me they don’t talk- I have to get the “superbill” and submit it to my husband’s insurance plan for each claim my new job’s insurance covers. Is that the best process? Can they really not talk at all?!

    1. Insurance Q&A*

      Sadly that’s how it works a lot of the time. I don’t know if you’ve tried this yet – You can ask your providers to forward the claim and EOB from the first insurance over to the second before billing you, and see what they say.

  81. willow for now*

    “I teach customer care reps, so I’m teaching them the rules, why things happen like they do, and then how to find the wiggle room and exceptions so that we can actually take care of providers and consumers.”

    So, you are Bob Parr (Mr. Incredible)?

    1. Insurance Q&A*

      Not to out myself, but my official superhero name is Chaos Coordinator.

      But shhhh it’s our secret.

  82. RedinSC*

    Thanks so much for the information. Appreciate your time and input! It’s great to have some advice on how to navigate things. Thank you

  83. LabTechNoMore*

    Might be a little too late for OP, but throwing this question out for anyone who is willing to answer. Last year I had a minor procedure that needed to be done, except my insurance company kept summarily denying the claim. Or rather, they wouldn’t actually deny it, they would somehow “lose” the paperwork and tell me the doctor I saw isn’t the doctor they approved, then instruct me to go to a different doctors office. This same lost the paperwork -> wrong docs office excuse was then given 4 more times over the course of 6 months, meanwhile I was paying several hundred dollars a month while unemployed.

    My question is, who holds these insurance companies accountable in cases like these, and how does one contact which ever regulatory body or government bureau that investigates these problems?

    1. CB*

      Typically this would be your state’s Department of Insurance, who should have a process for you to file a grievance against the insurance company. Other commenters have mentioned calling the office of one of your elected officials (state rep/state senator/US House rep), since those offices have been designated to resolve constituent issues.

      1. Insurance Q&A*

        Yuppers. The Department of Insurance might also go by Department of Financial Services or something similar. You can also tap in your elected officials or Attorney General’s office.

    2. NotMyRealName*

      Not an expert on this, but there should be a state commission on insurance. For an insurance provider to operate in a state, they have rules to follow. I’d google “[your state] insurance commission” and see what pops up there. Good luck!

    3. LabTechNoMore*

      Thanks everyone! I contacted my state rep’s office but never heard back. Good to know that there’s a Department of Insurance should I find myself in another Kafkaesque situation like above.

      1. LabTechNoMore*

        (Oh, and in case it wasn’t clear from the above post: I went to the doctor they told me to go to, only to be told it was the wrong doctor after the fact.)

  84. Boof*

    I also just want to chime in, as a physician, that /your physician’s office may already be doing some of the appeals for you/. I’m sure not everyone is the same; I’m an oncologist, often dealing with rare tumors or using things “off label” (maybe I have good evidence for why it would be helpful but for various reasons no official FDA approval yet). Generally I we try navigate all this for patients because we probably do it more often and most of our patients have a lot to deal with without wrestling with insurance.
    I think the biggest things you can do from a physician perspective is 1) don’t panic! 2) let us know if there is a problem (particularly a big bill) – we may be able to help. 3) we probably already know about denials and are working on them.
    … this may vary a lot by practice so if you get a denial it’s worth asking if they are working on it or if you should.
    One of the more frustrating things about medicine right now is we have these pretty awesome drugs (for certain applications) but have no idea what the out of pocket will be until we actually order them and try to fill them (it comes down to something about the pharmacy price and insurance I think). But pretty much everyone (Drug companies, patients, health care teams, medicare etc) WANTS people to be on the drugs if they need them so if the price ends up prohibitively high a lot of other things can happen.
    — NYS can get things “medicaid pending” or something so you can get care even if not [yet] covered
    — our [large] center has various patient assistance programs that will cover a lot of meds (I suspect a lot of the fundraising we do goes to these assistance programs) if you get them from our pharmacy; also sometimes gives out gas cards, grocery store cards, etc
    — there are regional drug assistance programs
    — drug companies have copay assistance programs because, again, they want people on their drugs
    — if we are denied twice by insurance for a drug we want, often we can apply and get the drug for free from the drug company (I’ve actually yet to NOT be able to get a drug we really want, but how long it takes depends how quickly the company will get through the appeals, and how responsive the drug companies are to the financial apps, etc – bigger drug companies are often very fast (just a few days to get approval) )

    So… there are ways, and there are ways. Alert your doctor if there is a problem; your doctor may have no idea it was a problem and may not know exactly how to work it out but they may well know who to go to to work on it. If they don’t know and don’t refer you themselves it’s probably worth asking to talk to social work.

  85. Earl Grey Tea*

    So I don’t have traditional health insurance. We use a health cost sharing company, which covers 100% of bills above $250 but doesn’t cover things like mental health, prescriptions, etc. While this means most everything gets covered (I had a complicated pregnancy with zero cost to me), it also means I have to keep track of Every Single Bill to submit to the company for reimbursement. SO, if you’re going through something major and need to keep track of your health expenses and insurance claims, I have a few tips:

    1. Start a spreadsheet. Keep track of the bill date, provider, description of care/services, amount owed, when paid and with what payment method, etc. As SOON as you receive a bill, put it in the spreadsheet. Do not wait, do not pass go, do not collect $200. You will forget. Live by the spreadsheet.

    2. Scan and keep digital files of ALL bills and receipts. Have some kind of folder organization that tells you which ones were paid. Paid a copay at the doctor’s office? Ask for a receipt and add it to your file.

    3. Call your provider’s billing office with each bill and ask if there is a discount for paying in full. Most providers will offer 10% off for bills over ~$300.

    4. If you’re visiting a provider that isn’t covered by your insurance, ask if they have a self pay discount. Most do!

    5. DO NOT put off calling your provider and paying a bill or setting up a payment plan. I had postpartum depression after giving birth a couple of years ago so pretty much ignored the bills coming in, and was sent to collections for a VERY large amount. I was able to get this taken care of quickly and our health cost sharing company paid 100% of the bill, but it was the most stressful time of my entire life. DO NOT DO THIS. Even if you can’t afford the payments they ask for, set up the plan and send them whatever you can.

    I have issues with avoidance and have major anxiety when it comes to money and paying bills (which my PPD just made 100x worse). I’ve pretty much fixed this by using my spreadsheet and filing system and forcing myself to deal with bills the minute they hit our mailbox. If you have a system, it’s harder to break the system and avoid your bills!

    1. Insurance Q&A*

      This is amazing advice. Setting up a system that becomes automatic for you, and not waiting to call, are both excellent strategies for managing medical expenses. (And life in general, but that’s more Captain Awkward’s area than mine)

  86. Verde*

    Couple of things I would add to this fabulous advice:
    – Employer plan brokers often have a help line to assist plan members, or the brokers themselves can run up the flag for additional help
    – Your HR and/or benefits administrator can give you information about who to call, resources available, etc. but they can NOT call the insurance plan on your behalf

    Good luck out there, all!

    1. the one who got away*

      YES! My employer’s benefits partner company (NOT the insurer) has a client advocate on staff and she is beyond wonderful. She helped me with an issue where I was billed out of network for a significant amount of labwork that I thought should have been in network. It was the lab within a major university hospital system based in our city. The insurer granted me an exception (with a lecture of course)…and then a few weeks later someone else at my workplace called the client advocate with the exact issue I’d had.

      Turned out our insurance company had miscoded the lab as out of network when it was not — and many of us had been overbilled by thousands of dollars as a result. I have the time and energy and skills to devote to chasing down health insurance stuff but a lot of folks don’t, and our CA said if she hadn’t had a second complaint she would never have known to investigate further. She was a lifesaver during a pretty scary health crisis (I’m fine now!).

  87. SingleMom56*

    struggling to find student insurance for a college that doesn’t offer it as an option. her primary care doesn’t accept “Obama care” type insurance and she takes a regular medicine that must be prescribed by a doctor (not nurse practitioner). trying to figure out “reasonably” priced insurance for her without losing her primary care.

  88. dedicated1776*

    Alison, I LOVE when you run Q&As like this. Thank you!!! And a huge thank you to your contributor for their time and expertise.

  89. NonProfit Survivor*

    This post and comments are so helpful. Thank you for taking the time, and +1000 on the suggestion for a blog!

    Do you have any advice on handling conflicts between insurers and medical groups? I have had multiple instances of wanting to enroll with doctors who are in-network according to my insurer, but then discover they are not part of the medical group. (?) I have also had the medical group deny claims for docs who are affiliated with the hospital system that is listed on my insurance card. I don’t completely understand the relationship between these two entities, and it’s hard to resolve conflicts.

  90. BenAdminGeek*

    Another thing to try too- if you have a high bill, ask for a payment plan, as recommended. However, you can either call or see if your provider/hospital will offer you a discount to pay early. We had a $2100 bill that after 2 or 3 small payments we got offered a 30% discount to pay in full. We had the money saved in our HSA, so it was a no-brainer for us.

  91. Sarah*

    Wow! I am a retired benefits administrator and can second everything the OP wrote. Like them, I got a lot of satisfaction resolving claim issues that gave good results for the employee.
    You be surprised at the lengths an insurance company will go to help someone under the plan. I once had an employee whose unborn child was determined to have a condition that would require treatment shortly after birth. The insurance company worked with her doctors and a treatment plan with high quality providers in the best hospital around was set up. Having the plan in place spared her the worry about dealing with it herself.

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