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5 Tips to Help Your Health Insurance Work for You

Facing what he considered to be a health care emergency, a Maryland consumer placed his daughter into in-patient drug treatment in another state. The facility had been recommended by a Maryland social worker who specialized in treating drug addictions. However, the consumer's insurer did not authorize the treatment and the facility was not part of the plan's network. The bill totaled $17,000 and the insurance company refused to pay, leaving the consumer responsible for the full amount.

The Consumer Protection Division's Health Education and Advocacy Unit receives many complaints each year from people who have received unexpected charges following a medical procedure. As insurance becomes more complicated and more and more health care providers participate in managed care plans, it is crucial that consumers know how their health insurance or HMO works and follow the procedures for receiving covered care. You will need to take care of all of these details before your medical procedure so you won't end up with bills your insurer won't pay afterward. Here are some points to remember:

1. Get a second opinion.

Before you have any kind of elective medical procedure or surgery, you should seek a second opinion. This is sound medical advice and is actually required by some types of insurance plans. Even if your plan does not require a second opinion, it will usually pay for it. You may have to use a doctor within your chosen group or plan. Check with your insurer to find out how this works in your particular plan.

2. Get proper authorization.

Many consumers contact their insurer to ask if a procedure is covered and are told it is covered by their benefits package. Later, they are surprised when the insurer refuses to pay their bill. Although an insurance plan may provide coverage for a particular kind of procedure, you may still need to receive authorization or meet certain conditions to have the insurer pay a claim for that service.
You need answers to two questions to determine if your health plan will pay for a medical procedure:

1. Is the treatment covered by the plan? If so,
2. Does your condition meet the plan's criteria to qualify for treatment?

These factors might complicate things:

Pre-existing condition limitations: If you had the condition for which you need treatment prior to joining the insurance plan, your insurer may not pay for the procedure.

Required preauthorization: If your doctors did not receive authorization to perform the procedure on you, it might not be covered even if you otherwise meet all of the qualifications for coverage.

Provider network limitations: Although your insurance plan may cover a certain procedure, your access to a particular physician or facility to perform that procedure may be limited by the medical group you choose within your plan.

Establishing medical necessity: Most plans require certain criteria be met to establish medical necessity for a procedure. If your doctor does not demonstrate that your condition meets the criteria to establish medical necessity, the procedure may not be covered by your plan.

Talk with the doctor who is to perform the procedure as well as your primary care doctor to be sure you receive proper authorization, and that the authorization covers all recommended treatment including follow-up care.

3. Be sure all providers participate in your plan.

You will need to check the status of each person involved in your treatment to be sure they participate in your insurance plan. Some other providers who may be involved include pathologists, radiologists, anesthesiologists, laboratories and assistant surgeons. Even if you are having surgery in a participating hospital with a participating surgeon, it is possible the anesthesiologist or radiologist may not participate in your plan.

Talk to the physician performing the procedure to determine who will be involved. Your insurer can help you determine who among them participates and whether the facility (hospital, outpatient surgical center) participates.

In some cases you will have a choice of providers and facilities. If your surgeon works at several hospitals, you can choose the one that participates with your insurance plan. The same may be true of other providers involved in your care. However, in some cases you may not have a choice. If you must deal with someone who does not participate in your plan, talk to your insurer. Some plans may agree to pay the difference in cost if you have no other options. Or the provider might agree to accept your plan's usual and customary payment. Depending upon the type of insurance you have, if a provider does not participate in your plan and won't accept assignment, you might be billed for the difference between what your plan will pay and the provider's charge for the service.

4. Talk about follow-up care.

Before the procedure, talk to your physician about what follow-up care you will need. If you will need physical therapy, for example, find out how many visits will be approved, under what conditions is coverage granted and who are the participating therapists in your area.

5. Coordinate benefits.

If you are covered under two different health insurance policies _ your own and your spouse's _ you need to address all of these issues with both insurance companies. Each plan may require different criteria and different authorizations. Coordinate your primary and secondary coverage before the procedure to be sure your bills will be paid afterward.

July 1997

Maryland Attorney General's Consumer Protection Division
Consumer hotline: (410) 528-8662 or 1 (888) 743-0023 toll-free

 
 

Attorney General of Maryland 1 (888) 743-0023 toll-free / TDD: (410) 576-6372
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