As healthcare consumers manage illness or chronic disease, and as they access diagnostic testing or treatment, they often experience anxiety and fear about the potential of pain and the uncertainty of the future.
On top of that, they are forced to live within the confines of their insurance policy, something which – often for the first time – requires them to pay close attention to what’s covered, what’s not, and what the parameters are in accessing care (e.g., referral requirements, staying within a network of doctors and hospitals).
Ideally, consumers would pay close attention to this when they enroll in an insurance product. But let’s be honest with each other … reading the details of an Evidence of Coverage document is not all that exciting.
And that’s why, at the intersection between accessing care from providers and living within the confines of insurance coverage, that frustration begins to bubble up.
A frustrating summer with long, long periods of time on the phone
When my parents became snowbirds, their change of address necessitated a change in theirMedicare Advantage Plan. Because they spend five months of the year in New England and come home for the major holidays, I purposely chose a national company that had a “Passport Program,” something that would allow them to access in-network care while home so that they could maintain relationships with physicians who’d treated them for years, and I could continue to accompany them to appointments.
And so as we planned for my dad’s total hip replacement this past June and some specialist care for my mom, we knew what we needed to do to enact their Passport Program. And yet it took at least an hour on the phone, per parent, to make this happen. We specifically asked if any referrals were required and were repeatedly told no. We were also told that no prior notification or authorization was necessary as we planned for dad’s surgery.
Despite that knowledge, I still had to make more phone calls and spend at least another five hours on the phone with various entities, one of which was a member of the administrative team from my dad’s surgeon’s office. Not only did I have to convince her of the requirements of the plan, continuously reiterating that a referral and prior authorization were not necessary, I had to deal with the threat of cancellation of his surgery if I did not obtain a referral.
We got through it, the surgery was not cancelled, dad is doing well, and all the bills have been paid.
My point, however, is that even with the knowledge and experience I have, the administrative barriers are sometimes so onerous that it can take hours of your time and lead to feelings of frustration.
Taming the administrative beast
Here are some things you can do to prevent frustrating experiences of this type:
- Pay attention to what you’re buying
As you enroll in employer-sponsored plans, Medicare plans, or buy insurance on the open market, be sure to pay attention to what it is you are purchasing. A great way to educate yourself is to call the insurer ahead of time and state you are contemplating buying a particular plan but, before you do, you want to know how it’s going to work in real life. Present a situation such as, “What if I need knee surgery in the year ahead that may include having an MRI and staying in the hospital for a day or two? How will the plan work?” Specifically ask what you need to do, what the provider needs to do and how you can expect claims will be paid.When I’m reviewing policies, I focus on the items listed below. If you review the same things when purchasing a plan, you’ll be ahead of the game.
- The premium
- The deductible
- The out-of-pocket maximum
- The network I have to live within
- How big-ticket items like hospitalizations will be paid
- Whether any out-of-network benefit exists and at what level those claims are paid
- Are my doctors and hospitals in the network
- Are there referral requirements
- Are there prior notification rules
- Are there prior-authorization rules
- Pick up the phone and call
The realist in me knows that even if you did a comprehensive job when purchasing your plan, you may not remember when you go to access care. So I suggest you do the following:Ask the business office representative in your provider’s office what their understanding is of how your plan works.
They often know when a referral is required or prior notification or authorization is needed. Bear in mind, however, that they may not always be right. As noted in the story about my dad, the representative was insistent upon certain things that were not necessary (because of his Passport Program). And while she later acknowledged that this product was not one she was familiar with, in the meantime, she caused me a great deal of angst the morning of surgery when she said we might need to cancel. (I did not share that with my dad as I spent yet more time on the phone; he had enough to worry about that day.)
Using the information you get from the provider’s office, call to verify.
When you call, have your Evidence of Coverage in front of you and ask the representative to reference the page and paragraph that addresses your question. That way, if you are in disagreement with what your provider thinks, you can reference the actual paper policy.
If there is disagreement, arrange a three-way call between you, the insurer and the provider’s representative.
This isn’t always easy to pull together, but I must compliment the insurance company representative who helped when I was troubleshooting for my dad. She was amenable to getting the provider’s representative on the phone and we finally got things cleared up.
Although insurance policies do not make for the most interesting reading, be sure to pay attention to what you are buying and to the rules you must follow when using the plan to access care.
Remember, should the administrative process fall apart, you are the one who will feel the impact. Being pro-active in this regard can save you a ton of time, effort, phone calls, and frustration in the future.