Your Top Health Insurance Challenges–Solved!

Trying to understand health insurance, knowing how to appeal a health insurance claim, and trying to organize insurance paperwork is tough. In fact, we surveyed over 1,000 women who told us just how difficult it is to understand health insurance. We culled your biggest challenges and got advice from leading health insurance experts.

Challenge: Making Sense of Policy Materials

Plenty of folks experience difficulty with health insurance before they even set foot in a doctor's office. 34 percent of survey takers said they have limited understanding of what services their plans actually cover; 35 percent had only fuzzy knowledge of their deductibles, premiums, caps, and co-pays.

When you signed up for your health plan, you probably got a thick packet loaded with policy details— and a lot of jargon. Good news: insurers are now required to send you a straightforward letter, called a Summary of Benefits and Coverage, that lays out in chart form exactly what's included in your plan. Deductibles, out-of-pocket limits, and what's not covered—all are spelled out in language the average human can understand. All summaries follow the same template, making comparison easier. A growing number of employers are offering two or more plans, so summaries are especially useful, says George Boué, an expert with the Society for Human Resources Management. 

A note about Explanations of Benefits, those letters that say "This is not a bill": 40 percent of respondents find them unhelpful or never bother to read them. Keep them! They're from your insurer to let you know what it thinks happened at your office visit. Peruse, reconcile with your experience, and cross-check with the doctor's bill. If that's impossible (or one doesn't come at all) call the provider for an itemized bill, says Pat Palmer, founder of Medical Billing Advocates of America.

Challenge: Communicating with Insurance Companies

Many survey respondents seem intimidated by the idea of contacting their insurers:

  • 44% admitted their confidence was shaky.
  • 76% said they wanted to learn more about successful communication strategies.

Luckily, your insurer is available in more ways than ever before. Here are the best ways to contact them:

  • Phone: Midday and midweek are best for the shortest wait time, says Brian McGuire, a director at UnitedHealthcare. (Monday mornings and firsts of the month are worst.) Record names, dates, and issues discussed in a notebook or digital file. "Be nice and be specific," says former insurance executive Lisa Zamosky, author of Healthcare, Insurance, and You (June 2013, Apress). Call-center staff can tell you about claim or appeal status, plan coverage, and in-network rosters. But don't be afraid to ask for a supervisor if you're not getting what you need.
  • E-mail: Sometimes you're in a rush, in the middle of a busy workday, and can't take a break to call your insurer during office hours. When you have time, go to your insurer's website, where you'll find e-mail addresses and forms you can fill out online to get simple is-this-covered or where-does- my-claim-stand answers. Include your policy number and, if applicable, your claim number, the date you received care, and the total amount of the bill. If possible, copy yourself on the e-mail—or just cut and paste the message into a selfaddressed e-mail so you have a record.
  • Virtual Chat: Virtual chat reps can answer only a limited number of questions, McGuire says. They are available once you're logged into your account on your insurer's website, and can help you find what you're looking for on the company site (even giving you links) or answer questions about what your plan covers. But resolve a claim or explain why a claim was denied? Probably not. For that, call and ask for a supervisor. But first, take a screen shot of any relevant information your virtual contact provided.
  • Mobile Apps: Smartphone apps are offered by some of the biggest insurers, including Blue Cross and Blue Shield, Aetna, Kaiser Permanente, and UnitedHealthcare. Check to see whether your app will connect you directly with customer service reps for claims, billing, approvals, or pharmacy.
  • Social Media: Complaining about your insurance situation online might get a response from your insurer, but Zamosky advises against it. In general, avoid exposing your private details to millions. "We don't encourage anyone to do this," McGuire says. "But we do have a process in place so if anyone does use social media this way, we get it in a direct route to where it needs to be."

Challenge: Tracking Out-of-Pocket Costs

For many people, health care expenses go well beyond the monthly premiums on their plans. But 39 percent of respondents said they were fuzzy on how much of their hard-earned cash went to out-of-pocket costs in a given year.

  • Why it's Important: Come tax time, you might be in for a major break. A number of medical expenses can be deducted on itemized federal income taxes. IRS Publication 502 is your deductions guidebook.
  • How to do it: Explanations of Benefits or a combination of invoices, canceled checks, credit card and bank statements— anything that lists whom, how much, when, and for which services you paid—should satisfy the IRS, says Amy Bergner, human resources expert at PwC. To track transportation expenses, keep a notebook in your car to log mileage, or get receipts for taxi or public transit services.
  • Organization is Key, but Also Simple: To track spending, an accordion file on your desk works as well as a scanner and a special file in your DropBox. Or Simplee and CakeHealth are designed specifically for managing healthcare expenses. Evernote allows you to snap photos of receipts on your phone and organize them on your desktop. Plus, a lot of tax prep software allows you to track health spending throughout the year so you don't have to spend hours entering it at tax time.

Challenge: Saving Cash Without Cutting Care

In an effort to decrease the cost of co-pays, prescriptions, and other out-of-pocket expenses, some respondents have resorted to iffy strategies:

  • 49% have delayed procedures or appointments.
  • 33% have skipped or cut back on a medication.

However, there are several strategies that can help you get the care you need without breaking the bank:

  • Consider Location: In-network urgent care costs less than an ER visit, so if you have an infection, cut, or broken bone, visit the former. The same goes for outpatient surgical centers, which are great for one-day procedures and cost less than hospitals. Ask your provider where he's licensed to work, then check with your insurer to see which location will cost less, Palmer suggests.
  • Negotiate: If your plan requires you to pay everything until your deductible is met, first find the market price of the service you need at a website like Fair Health. Then ask the doctor her fee. If it's higher, ask whether she'll take the lower amount if you pay cash, Zamosky says. Remember to get a receipt to submit.
  • Ask for a Payment Plan: How much can you afford to pay monthly? Propose that to the billing department—interest-free, Zamosky says. Mark your calendar so you pay on time.
  • Upgrade Your Plan: If you have chronic conditions that require medications, a higher-premium plan with better prescription coverage could save hundreds in the long run, says Larry Levitt, senior vice president at Kaiser Family Foundation.
  • Go Generic: Brand-name and generic formulas can be slightly different— but generics are much cheaper. Ask your provider about them.
  • Find Alternatives: Similar, less-expensive drugs might be out there. Ask your doctor for options and check with your insurer about price.
  • Seek Samples: If your condition is short-term, your provider might have sufficient samples in his office.
  • Mail in Savings: Some insurers offer discounts if you opt for automatic payment and mail delivery of meds. Some generics cost less than $10 for a 90-day supply; specialty and brand-name drugs increase from there.

Challenge: Filing Appeals When Coverage is Denied

In many cases, medical appointments and procedures are followed by an unpleasant surprise: 30 percent of survey takers said they've been billed for something they believed was covered. And many end up eating those unexpected charges: 57 percent of respondents said they aren't sure how to appeal a coverage denial, and 23 percent of respondents said they've actually avoided filing appeals because the process seems too complicated.

But take heart: Going to the trouble of an appeal is often worth the effort. More than half of all appeals are decided in the consumer's favor, Zamosky says.

  1. Know the Process: Insurers are required to provide information about the appeals process, so read any extra papers included in the letter of denial. If you can't find it, search for the info on your insurer's website or call the company to request the form be e-mailed to you.
  2. Study Up: Skim your policy for the section that pertains to your claim. If you can't find it, e-mail, call, or have a virtual chat with your insurer to pinpoint the area in question, says Martin Rosen, cofounder of Health Advocate, an advocacy and assistance group. "Your policy is a contract," he says. The more you know, the better case you can make.
  3. Gather Your Evidence: Explanations of Benefits (EOBs), bills, medical records—all of it helps you make your case. Put everything together in one place and make copies to send along with your appeal letter.
  4. Make Your Case in a Letter: Include all the usual things—your policy number, the date and location of the service that's in dispute, and the provider. Cite the portion of your policy that discusses the issue at stake. Attach copies of those EOBs, bills, and medical records—never send the originals—and then cite what the policy says it will cover.
  5. Have Your Doctor Vouch for You: A letter from your physician explaining why you received the care you did is essential, says Medical Billing Advocates' Palmer. But that's not all your provider can do for you. Ask for an operative report—an explanation of the services performed. "If there were issues during the procedure, if the procedure needed to happen in a certain period of time, or if they needed to do additional procedures once they'd begun, that info will all be on the operative report," she says. "That can increase how much an insurer will pay."
  6. Ask for an Outside Review: Appeals can go through at least three levels. The first sends your appeal to whoever denied your claim; the second goes to an objective person in the company; the third goes to an independent third party. But you don't have to wait to get to the independent review board. Under the Affordable Care Act, most plans are eligible for such a review. Ask for one in your appeal letter. "They don't volunteer to give you the outside appeals board," Palmer says. "But you have the right to ask. You may get a more impartial hearing this way."


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