Health plan ignorance can cost you

November 2, 2007

When her husband needed specialized care, the author realized she'd been ignoring her own advice.

Every day, patients ask me about their insurance coverage.

"Is that specialist covered by my plan?"

"Does my health insurance cover that treatment?"

"Do you know which mail-in prescription plan I have?" Or: "Do I have a mail-in plan?"

My answer is always the same:

"As a good consumer, it's your job to know what your health plan covers. It'll make your life easier if you know you have to use a specific hospital, lab, or pharmacy. And it'll save you a ton of money if you know in advance which doctors and facilities are your plan's preferred providers."

There's no way I could possibly keep up with the intricacies of every plan, I tell my patients. "But you only have to keep up with one plan . . . your own."

I put the responsibility where it belongs-with the patients, trusting they'll be better served by understanding their own coverage. This not only helps patients navigate the healthcare system, it gives them the perfect opportunity to vent their frustrations to the people who may be able to make a difference: their plan representatives.

I should have taken my own advice

My husband, Paul, sustained a serious fracture to his shoulder last spring. The local orthopedic surgeon thought it would be too complicated to handle himself, and suggested we see a trauma specialist 45 miles away in Grand Rapids. Trusting his conservative judgment, we complied. Good thing we did, because Paul needed an emergency joint replacement. The shaft was comminuted, and so was the humeral head. Surgery went well, and after a four-day hospital stay, Paul went home.

Fred, the local orthopedic surgeon, offered to do the post-op care and rehab referral. This was great news, since we wouldn't have to drive to Grand Rapids. I called the trauma surgeon's office to say that we wouldn't be coming back for Paul's first post-op appointment. That's when I learned that the surgeon who had operated on Paul didn't participate in our Blue Choice plan. In fact, his office didn't accept any Blues plans at all. Yikes!

In the meantime, Paul started an intensive rehab program at the independent physical therapy center in town that Fred recommended.

Soon we started getting EOBs in the mail, explaining the various benefits paid (or unpaid) on Paul's behalf. The first one identified the $25 copay we owed for the initial emergency room visit. An EOB for the surgery followed, showing our responsibility for the outstanding balance of nearly $1,700. There was an additional charge of another $25 for that emergency room consultation.

When the EOBs for Paul's rehab sessions showed up, I was confused. It seemed odd that the PT facility didn't participate in our plan, since it advertised that it belonged to virtually every health plan in existence. What's more, someone from the facility had called the Blues before my husband's first appointment to give us a printout explaining our copays and deductibles. We were responsible for the first $250, and then about $20 per visit. With several months of rehab ahead at three times per week, we were looking at another thousand dollars, easy.

But no matter. We were fortunate to be able to pay these balances without difficulty. Our plan paid at the out-of-network rate, and we paid the balance. I charged the full balance at the orthopedic office, and was rewarded with a prompt-pay discount. Bonus: We got airline miles!